CLIMATE CHANGE,

INDOOR AIR QUALITY

AND HEALTH
Prepared for

U.S. Environmental Protection Agency

Office of Radiation and Indoor Air

August 24, 2010

By

Paula Schenck, MPH

A. Karim Ahmed, PhD
Anne Bracker, MPH, CIH
Robert DeBernardo, MD, MBA, MPH

Section of Occupational and Environmental Medicine

Center for Indoor Environments and Health

Climate Change, Indoor Air Quality and Health

By
Paula Schenck, MPH
A. Karim Ahmed, PhD
Anne Bracker, MPH CIH
Robert DeBernardo MD MBA MPH
University of Connecticut Health Center
Section of Occupational and Environmental Medicine
Center for Indoor Environments and Health

1. Introduction and problem statement ......................................................................................1

Background .........................................................................................................................1
2. Climate change and health as relates to indoor environment ...............................................3
National Institute of Environmental Health Science 2010 report........................................3
3. Environment and agents of concern in the indoor environment ..........................................4
Temperature ........................................................................................................................4
Outdoor air contaminants and indoor air quality .................................................................4
Components of indoor air, links with adaptation measures and climate change .................4
4. Green buildings, indoor air quality and health .................................................................10
Energy policy and regulation .............................................................................................10
Green building, definition and attributes ...........................................................................10
Buildings and illness ..........................................................................................................12
Green building certification ...............................................................................................12
Weatherization and retrofit construction ...........................................................................13
Available guidance.............................................................................................................14
5. Recommendations and outlook on public health and health provider roles ........................15
Green buildings and public health practice........................................................................15
Surveillance, sentinel case model and prevention .............................................................16
Health information technology ..........................................................................................17
Access to sensitive and vulnerable groups through community health centers.................18
Clinicians public health leadership ..................................................................................18
6. Conclusions.........................................................................................................................20
7. References............................................................................................................................21
Appendix A: Trainings for professional communities on buildings and health ......................27

This manuscript was developed for the U.S. Environmental Protection Agency (EPA),
Office of Radiation and Indoor Air, Indoor Environments Division. This report presents
the findings, recommendations and views of its authors and not necessarily those of the
U.S. Environmental Protection Agency.

1. Introduction and problem statement

In the United States, Americans spend an estimated 90% (EPA 2009) - 92%
(Bernstein et al. 2008) of their time in indoor environments. The quality of our indoor
environments is a key determinant to the quality of life and health. With climate change,
attention to building quality has increased as the indoors is expected to become more of a
refuge against heat and climate events. Improving building quality also offers an opportunity
for more efficient use of energy. In the United States, estimates of proportional energy use
attributed to buildings range from 38.9 % (EPA 2009) to 48% (Architect 2030, 2010).
Furthermore within 30 years, the majority (up to three-quarters) of our built environment is
projected to be replaced with new and renovated construction (Architect 2030, 2010). There
is a clear imperative for designing energy efficiency into building operations. How we
construct and change these indoor environments to accomplish this imperative has the
potential to contribute to or possibly subtract from the overall well-being of those who live,
work or go to school in these indoor spaces.

Background
The anthropogenic contributions to climate change will be a subject of continuing
inquiry. However, the current national dialogue around climate change has shifted from
mainly a debate about the phenomena and projections of impact to a discussion of actions to
reduce green house gas emissions and mitigate atmospheric/global warming, and measures to
adapt to likely global warming consequences. This shift coincided with national policy for
economic stimulus, creating a focus and allocating resources for green programs. These
actions provide an opportunity to substantially improve the quality of indoor environments
and to advance public health. But it is critical to fully recognize the complex relationships
among 1) indoor environmental quality, 2) energy efficiency, 3) environmental sustainability
and 4) human health. Without an in-depth appreciation of the interwoven nature of these
relationships and definite actions to integrate all four elements into planning, there is
likelihood for adverse effects to the quality of our indoor environments and associated threats
to health, especially to the most at health risk populations.
The public health and clinical communities share responsibility to serve the health
needs of the population, especially the young, the old, the immune compromised, and the
socio-economically disadvantaged. As programs are developing health professionals will
need to work with environmental experts to craft a national response to climate change. This
response should: 1) prepare for anticipated health consequences from climate change by
identifying programs designed to prevent and/or minimize outcomes; and 2) recognize the
potential for and propose measures to avoid unintended health risks that may be coincident
with energy efficiency measures. However leadership in the environmental, energy, public
health and health provider communities will need to be nurtured and educated on the
complex inter-connectedness among energy efficient actions, environmental sustainable
materials and occupant health.
With recognition that developing policy and new resources will affect indoor
environments and the potential for public health benefit, the Center for Indoor Environments
and Health at the University of Connecticut Health Center (UCHC) assembled a team to

identify some aspects of climate change and adaptive measures that would likely affect
indoor air quality and the health of occupants. Paula Schenck, MPH (Assistant Director,
Center for Indoor Environments and Health (CIEH)) is the primary author. A. Karim
Ahmed, Ph.D. (Director, International Programs, National Council for Science and the
Environment and Adjunct Professor, Occupational & Environmental Medicine, UCHC)
contributed to the discussion of sources and provided insight into the science underlying
climate change mitigation and adaptive measures. Anne Bracker, MPH CIH (senior
industrial hygienist, CIEH) provided a focus on the unique vulnerabilities of our workforce
and identified critical needs for training. Robert DeBernardo, MD MBA, MPH (an allergist
affiliated with the CIEH) contributed to the discussion on surveillance and prevention.
Martin Cherniack, MD MPH (Director of Occupational and Environmental Medicine Center,
UCHC) guided the authors on role of health providers and provided a comprehensive internal
review. Paul Schur, MPH (Director of Environmental Health, retired State of Connecticut)
and Paul A. Weinberger, MS (with expertise in energy and environmental technology)
provided independent reviews and contributed suggestions to the final paper.
This manuscript has six subsequent sections. The first briefly identifies the current
consensus on climate change and health as it relates to indoor air quality and diseases of most
concern. The next section summarizes the agents of concern to human health in the indoor
environment and the potential impact from adaptive building measures to global warming.
The next segment describes green building programs, suggests an expanded definition and
identifies questions that need to be resolved in order to make current certification processes
effective for indoor air quality. The fifth section discusses environmental public health and
healthcare community involvement and leadership with specific recommendations to address
indoor environment. After a brief concluding section and list of references, a chart
summarizing key components of trainings for professional communities with tasks that
impact on buildings and health is presented in Appendix A.

2. Climate change and health as relates to indoor environment

Consensus scientific groups have concluded that climate change will affect human
health (Confalonieri et al. / IPCC 2007, US Global Change Research Program 2009, NIEHS
2010). Identified agents of concern include overall heat, ultraviolet penetration, biological
materials such as pollens, molds and infectious agents, and air pollutants, especially ozone
and particulate matter. Exposures to these agents are generally expected to increase with
climate warming trends.

National Institute of Environmental Health Sciences 2010 report

Contributing to the discussion on health, the National Institute of Environmental
Health Sciences (NIEHS) convened an interagency working group with representatives
(among others) from federal entities with charters in many related fields- EPA, Centers for
Disease Control and Prevention (CDC), US Department of Health and Human Services, US
Department of Agriculture, National Oceanic and Atmospheric Administration, NIEHS and
the University Corporation for Atmospheric Research with a charge to identify the research
needs on human health effects of climate change. The report A Human Health Perspective
on Climate Change- outlines relationships between human health effects and climate change,
and identifies suggested areas for future research.
The report is organized by disease outcome. It identifies specific agents including
allergens such as pollen and mold spores and components of air pollution such as particulate
matter as agents of concern. Although the NIEHS report does not specifically address indoor
contaminants or transformations of outdoor constituents in the indoors, it identifies pertinent
relationships between outdoor air pollutants and health outcomes. The report calls for
careful analysis of mitigation and adaptation co-benefits and strategies. Quality indoor
environments can be a recognized co-benefit of energy efficiency. However, there are
unrecognized obstacles to fully developing this co-benefit.
Also of interest to the subject of this paper, the research needs enumerated in the
chapter on asthma, respiratory allergies and airway diseases call out these specific actions
which are coincident with actions endorsed in this report:

identifying ..populations and communities at increased risk of climate-related

respiratory disease..
studying the health effects of airborne and indoor dust on asthma exacerbation,
including changes in dust composition resulting from climate change..
examining chemicals used in energy efficiency technologies to ensure that they do not
contribute to lung sensitization, asthma, or other respiratory disease..
developing decision support tools including health impact assessments of the burden
of respiratory disease attributable to climate change for help in identifying and
selecting air quality mitigation and adaptation policies that will promote health
benefits..
(Portier et al. 2010, p15)

3. Environment and agents of concern in the indoor environment

Temperature
Atmospheric temperature and outdoor pollutants are contributors to indoor air quality.
Extremes of temperature in particular are associated with increased cardiovascular health risk
(Langrish et al. 2009, Bhaskaran et al. 2009.) A review of emergency room use and hospital
admissions during the 2006 heat wave in California identifies that prior acclimation to heat
seems to mitigate health care utilization (Knowlton et al. 2009). Surveillance in France
during heat wave events in Europe identified the over 75, elderly at risk (Josseran et al.
2009). As the older US population will increase- the over 65 population is projected to rise
from 12% of the population currently to 21% by 2050 there is an increased risk for heatrelated illness in this group with climate change. Indoor shelter is key to protecting against
heat-related conditions and risk of death (US Global Change Research Program 2009).
Green roofs to reduce urban heat island effects, air conditioning to control heat and humidity,
warning systems and available public areas of refuge are measures to address excessive heat.

Outdoor air contaminants and indoor air quality

Programs that sustain and improve outdoor air quality are important to indoor air
quality. The National Ambient Air Quality Standards ([Link] )
provide goals for the concentrations of constituents in outdoor air that are known to affect
health. The program drives development of less polluting energy generation technology.
Because the Clean Air Act established EPAs authority to develop health-based standards for
outdoor air, health effects from these pollutants and postulated mechanisms are continually
reviewed, elucidated and discussed in the academic and environmental science communities.
Once contained indoors, air becomes a repository of gases, moisture and particles
originating from occupants and materials. Pollutants are also formed de novo from the
mingling of various constituents in the indoor environment. For example, when contacting
materials and gases in the indoor environments, ozone reacts with chemicals producing
additional contaminants of concern (Weschler 2006, Wisthaler and Weschler 2010). Indoor
levels of pollutants may be 2 to 5 times, and occasionally 100 times higher than outdoors
(EPA, 2009). Ventilation systems are designed to filter out some contaminants and mix in
enough fresh air to maintain a level of quality in the indoor air. The literature on indoor
pollutants and indoor transformations is less robust than that addressing ambient air quality
health effects but never the less the association of indoor environmental quality with health is
established, especially for radon and moisture (Field et al. 2000, Mudarri and Fisk 2007).

Components of indoor air, links with adaptation measures and climate change
The balance of this section briefly discusses selected constituents of indoor air of
concern to human health and identifies their links to climate change and energy efficiency
actions. Because categories of sources were chosen for discussion based on characteristics,
relevance in consideration of health and climate change, and to some extent the existing
regulatory framework; some of the categories necessarily overlap.

Biological contaminants proliferate in damp areas of homes and business office

buildings. Moisture in homes is associated with illness- in particular occupant asthma
and respiratory symptoms (IOM 2004; Mudarri and Fisk 2007; WHO 2009). Some
possible agents of concern include fungi and fungal products, bacteria including
endotoxin, dust mites, cockroaches, pets and pests. Some fungal organisms found
indoors when moisture sources are not controlled belong to the genera: Aspergillus,
Cladosporium, Penicillium and Stachybotrys. In some individuals exposure to
biological materials contribute to irritant and allergic illness from respiratory
distress, eye and nasal irritations, laryngitis and hoarseness, flu-like symptoms, and
headaches to asthma and allergy initiation, aggravation of pre-existing asthma, lower
restrictive respiratory disease and skin allergies (Storey et al. 2004, Cox-Ganser et al.
2009; Park et al. 2008).
Any available water from: leaks in roofs, walls, windows, plumbing; basement
seepage; humidity and condensation, encourages biological growth. Climate change
will increase heat and humidity in some areas of the United States, likely resulting in
an increase in mechanical air conditioning and may increase the generation of
biological material indoors. Appropriately sized and adequately maintained
ventilation units should help control biological growth by supporting acceptable
levels of humidity, limiting condensation on cooler surfaces and addressing pooling
water (for example accumulated water in drip catch trays in air conditioners).
Climate change is also expected to increase the occurrence of extreme weather
events. Mold and bacteria will grow in homes and buildings that are inundated with
flood/storm water (CDC 2006) or are exposed to excessive dampness over a
prolonged period.
Climate change and coincident ecological change is expected to affect the presence of
indoor infectious contaminants. Legionella bacteria have been found in air
conditioning water towers. With excessive precipitation events, turbidity may
increase in potable water supplies suggesting that better filtration of water entering
buildings would be appropriate as part of the control against Legionnaires disease
(Morey 2010). Other human pathogens are associated with soils and dusts and could
become more prevalent indoors in green buildings with green roofs and green atriums
in some areas of United States, indicating the importance of dust suppression indoors
(Morey 2010).
Tighter buildings (less dilution with outside air) may increase the likelihood of
airborne spread of person-to-person infections and may call for additional control of
infectious agents. Ultraviolet irradiation of ventilation system in plenums where
return air is mixed with fresh air is a sometimes used remedy. This adds a
maintenance challenge and can pose risks to custodians health. In general, the
overall utility of adding a disinfection process to ventilation to improve indoor air
quality has not been established. The exception of clean rooms in healthcare and
laboratory settings is a limited precedent.

Combustion formed gases such as carbon monoxide (CO), nitrogen oxides, and
sulfur dioxide gases are from natural gas or wood-burning stoves, oil and gas
furnaces, fireplaces, kerosene heaters, lighted candles and other combustion sources
within the building structure. Environmental tobacco smoke contains carbon
monoxide as well. Vulnerable populations are at more risk, possibly because of
variable home maintenance and inappropriate uses of combustion appliances,
including kerosene space heaters. Elevated nitrogen dioxide levels are reported more
often in lower income housing (Bernstein et al. 2008). Improper ventilation of these
gases can lead to occupants irritant symptoms, respiratory symptoms, effects on lung
function and increased risk of respiratory infection. CO poisoning is of particular
concern and is a recognized threat to the elderly population. Lower exposures cause
sleepiness and flu-like symptoms; while more extreme exposures have brought about
severe neurobehavioral effects, coma and death. In general, these gases do not build
up high air concentrations in drafty homes and/or properly ventilated buildings.
However, weatherization activities that make building structures more energy
efficient by sealing windows and other areas of air leakage could increase exposure to
these gases and pose a higher health risk to the buildings inhabitants (Richardson and
Eick 2006). Experience with hurricane Katrina raised a concern over occupational
CO exposures from cleanup equipment used indoors (Schulte and Chun 2009).

Fibrous insulating materials are used to maintain energy efficiency of heating

systems in buildings. Contact with fibrous insulating materials can cause dermatitis
and has been indicated with pulmonary disease (McDonald et al. 2000). At one time
asbestos was commonly used as a fire-resistant component of ceiling tiles and
insulation material in building plenums, air ducts, furnaces, boilers and around hot
water pipes. Although asbestos-containing material is not indicated in new buildings,
certain types of friable asbestos fibers, if improperly contained in buildings including
within ventilation systems, would be a health risk to its inhabitants. Materials (not
previously identified as containing asbestos) when disturbed during weatherization
and retrofit activity pose a hazard to construction crews.

Formaldehyde can be found in the indoor air of homes and buildings where wall
paneling is made of pressed-wood products that contain urea-formaldehyde resins.
Formaldehyde is a colorless gas with a pungent odor and corrosive chemical activity
that may cause eye irritations, nose bleeds, persistent headaches and breathing
difficulties. It is known to aggravate asthma and cause severe allergic responses in
some individuals. It is a potent sensitizer and is considered to be a probable human
carcinogen based on life-time animal bioassay studies. Severe illnesses related to
formaldehyde exposure were reported by inhabitants of mobile homes that were used
as temporary shelters after Hurricanes Katrina and Rita in the Gulf Coast (2005) and
the upper Mississippi River floods in Iowa (2008). An increased reliance on
emergency housing may follow increasing occurrences of catastrophic climate events.

Lead is a health problem among young children in low-income, inner-city homes.

Sources of lead in homes occur mostly through formation of dust particles flaking
from lead-painted walls or from tracking lead-contaminated soil from outdoors. Lead
exposure may occur from windblown lead-contaminated dust during hot summer
months from open windows or through cooling window fans. Extreme weather
events with associated increase in mud and dirt tracking in homes may add to indoor
lead exposures. An exploration of seasonal variability in lead dust levels in homes
indicated a linear relationship between lead loading in indoor dust and precipitation
rates (Petrosyan et al. 2006). Healthy homes programs remediate homes to intervene
on occupant lead exposure. In addition precautions against worker lead exposure are
appropriate mandatory during weatherization and retrofit activities.

Ozone there are two chief sources of indoor ozone: copy machines and electrical
appliances, such as air purifiers and other electronic devices; and outdoor air
infiltrating indoors during hot summer months. Outdoor ozone levels rise in cities
with warmer temperatures because of the urban heat effect (i.e., urban regions are
generally 5 to 6 degrees Celsius higher than rural areas). Here the photochemical
oxidation of hydrocarbons with nitrogen oxides to form ground-level ozone is
considerably enhanced at higher temperatures. Indoor ozone can have an interactive
health impact with other air pollutants, such as nitrogen oxides, fine particulate matter
and formaldehyde. Ozone affects pulmonary function in both healthy individuals and
those with respiratory disease. Young children, the elderly and those with chronic
respiratory or cardiovascular problems are more vulnerable to ozone. For those with
asthma and other allergic disease, exposure to ozone can contribute significantly to
the allergic response (Bernstein et al. 2008).

Particulate matter and smoke Particulate matter is a criteria pollutant in outdoor air
regulated under the Clean Air Act. Additional indoor sources of particles include
environmental tobacco smoke; heating boilers and stoves; building materials; house
dust; and consumer products. Health effects associated with fine particulate matter
include respiratory symptoms, asthma exacerbations and heart arrhythmias. The
Childrens Health Study in Southern California has shown associations between
reduced lung development and function in children and particulate pollution
(Gauderman et al. 2004). With an increase in desert area in the US from a warming
climate, atmospheric levels of particulate matter are expected to increase. In addition,
forest fires, whose occurrences may increase with climate change, will add episodic
particle pollution to outdoor air, increasing the contaminant burden indoors. Beyond
the obvious burden of death and immediate healthcare utilization, forest fires adverse
effects include irritant and respiratory symptoms (Kunzli et al. 2006).

Smoke and particles are generated indoors by the burning of wood in fireplaces,
cooking and heating stoves. Wintertime wood burning is expected to increase as a
means to lesson reliance on oil and gas. This practice increases outdoor pollution and
has been reported to contribute substantially to indoor pollutants (Washington State
Department of Ecology 1997). In colder climates wood burning (including
individual units outdoors) has been proposed as an adaptive measure to maintain
power during expected power outages caused by extreme weather. Unless
appropriate controls are imposed, this practice will contribute to poor air quality and
negative health effects (Belanger et al. 2008). Wood smoke can contain carbon
monoxide, particulate matter and other irritating or toxic components including
acrolein, benzene, formaldehyde, and polycyclic aromatic hydrocarbons. Some of
these materials are characterized as severe respiratory irritants and/or probable human
carcinogens.
Although not in widespread use in the US, smoky cook-stoves are major causes of
death and disability in households in developing countries. The risk of morbidity and
mortality from pneumonia is increased for children in homes where biomass fuels are
in use (Dherani et al. 2008). Because black carbon (BC) forms from biomass fueled
cook-stoves (and appliances that burn diesel fuels), this source of indoor pollution has
become a major concern not only to reduce direct health consequences but
importantly for the potential mitigating impacts to climate change of reduced BC
emissions. The warming effect from BC emissions has been assessed as the second
or third largest contributor to global warming and may be responsible for as much as
a quarter of the global warming over the last century (ALA 2007, Wallack and
Ramanathan 2009).

Radon is an odorless and colorless radioactive gas that infiltrates into the indoor air
from home and building soil foundations. Factors that direct the potential for radon
gas accumulation in buildings include the specific geographic location and
characteristics of the building foundation and soil barriers. The Iowa radon lung
cancer study reported that cumulative radon exposure in homes is significantly
associated with lung cancer risk ( Field et. al. 2000). Some studies show a
multiplicative interaction of radon with tobacco smoking (EPA 2003). Even though
radon has a short radioactive half-life (3.8 days), it is the second leading cause of lung
cancer in the United States. Radons health effects are primarily due to its radioactive
daughter products polonium 214 and 218. Both are alpha particle emitters that
produce deposition on human lung linings. Without proper remediation to vent off
ground-level radon gas on an ongoing basis, radon can accumulate in some buildings
above established action levels (greater than 2 to 4 picocuries/liter) and produce
unacceptable exposure and organ radiation. While acting directly to address a
potential serious health threat, assessing the risk for radon exposure and if indicated
incorporating mitigation measures in new building design may have the ancillary
benefit of reducing the likelihood of other soil gases emanating and /or moisture
penetrating below grade building assemblies into occupied space (ASHRAE 2009).

Volatile organic compounds (VOCs) and other chemical emissions VOCs will
increase at higher ambient temperatures. They are found in common household and
office building materials, furnishings, finishes and a variety of commercial products.
Well-sealed indoor air environments can concentrate chemical emissions. Specific
sources of volatile compounds include dry-cleaned clothes, cleaners, paints, paint
strippers, solvents, adhesives, furniture coatings, fragrances, carpets, pesticide sprays,
and stored fuels. Under damp conditions, fungi amplify indoors, produce VOCs, and
are detected by a commonly recognized moldy, musty odor.
Some chemicals (including phthalates and pesticides) that may emit from indoor
materials can have irritant, allergic, toxic or carcinogenic properties. Spray
polyurethane foam insulation, used in weatherization, may be concerning because of
irritant properties and specific effects of components on respiratory health and
asthma. Exposure during application is a particular hazard to weatherization crews.
Since specific guidance is often lacking in new building design and renovation,
general practices of minimal time for off-gassing before occupancy and reliance on
labeling/certification programs for material selection may not be adequate to
eliminate/reduce occupants exposure to health-concerning chemicals (ASHRAE
2009, Wargo 2010). Control of moisture to inhibit biological growth is the only
effective means to eliminate biologically generated VOCs indoors.

4. Green buildings, indoor air quality and health

Energy policy and regulation
The imperative to reduce greenhouse gas emissions has focused appropriate attention
on energy use in buildings. With climate change, the need for air conditioning is expected to
outstrip savings from reduced heating demand, potentially adding to the energy burden. As
the existing building stock is replaced with new and renovated construction, attention to
energy efficiency is paramount. This fuels a developing industry that fosters development of
energy efficient and environmentally sustainable buildings within the architecture,
construction, manufacturing, consulting and engineering sectors.
Public health is cited as an ancillary benefit from this energy policy. Models that
assess the co-benefits to health from energy reform rely on reduction of outdoor pollutants
coincident with changes in energy production and use (Smith and Haigler 2008) and with
reduced residential energy consumption (Levy et al. 2003). Costs associated with indoor air
quality exposures are considered less, if at all; so the assessments may miss identifying some
health risks in the design of some energy-efficient buildings. Health effects research that
broadly elucidates the cost of poor indoor environmental quality is not generally available. A
notable exception is the study of Mudarri and Fisk (2007) which estimated that annual cost of
asthma attributable to dampness and mold exposure in homes between $2.1-4.8 billion.
Model energy codes are available to planning agencies, and some state and local
jurisdictions have adopted energy codes for housing and commercial buildings. EPA offers
a fact sheet ([Link]
that presents the advantages of energy codes to energy efficiency, overall environment and
economic status. Building codes are variable among states (and municipalities), often
difficult to enforce, and give limited, if at all, attention to indoor air quality. Coupling codes
with indoor air guidance for construction such as found in EPAs Indoor Air Plus program
(EPA 2009) could be an important addition to these efforts. Countless state and municipal
(Bernstein 2008, Bernstein and Lamb 2003) actions independent of codes mandate attention
to energy utilization in buildings especially (but not exclusively) when public funds support
building construction and renovation.

Green building-definition and attributes

EPA defines green building as follows:
Green building - also known as sustainable or high performance building - is the practice of:

Increasing the efficiency with which buildings and their sites use and harvest
energy, water, and materials; and
Protecting and restoring human health and the environment, throughout the
building life-cycle: siting, design, construction, operation, maintenance,
renovation and deconstruction.

(EPA 2009)

Building design and/or retrofit activities with structured attention to the factors noted in the
definition directly affect the indoor environmental quality of the structure.

10

In addition to demonstrating energy efficiency and environment sustainability,

buildings with a green building label should have two other attributes: be health-supportive
and utilize green technology. The four attributes are noted below.

Energy efficiency requires establishing defensible energy use benchmarks and a

means of attaining and measuring reductions in energy use. The EPA Energy Star
program for homes provides a method to establish initial benchmarks and set
appropriate goals. Models are used to determine the energy conservation benefit of
design elements. A review of energy use information to determine actual building
performance is important.

Sustainability is the ability to achieve continuing economic prosperity while

protecting the natural systems of the planet and providing a high quality of life for its
people. (EPA-d 2009). In practice, consideration of resources (especially energy
and water), characteristics of materials (renewability, hazard), and the sources of
building materials (local verses long distance, etc.) underlie sustainability
determination. Life cycle modeling could be a strong tool to contrast sustainability
of alternative designs; however establishing criteria that underlie life-cycle
approaches is a prerequisite. The National Institute of Standards and Technology
Building and Fire Research Laboratory is currently exploring metrics and tools for
assessing life cycle and economic performance (Helgeson and Lippiatt 2009).

Health-supportive is more than producing buildings that serve to minimize overall

health impacts to the environment (including from climate change). For buildings to
be health-supportive the design should foster an environment that supports occupants
health, well being and productivity. Aesthetics, lighting, acoustics, thermal comfort,
material choice, and indoor air quality are areas contributing to a health-supportive
design. Attention to minimizing occupant exposures through ventilation, source
control, material selection and maintenance planning - is critical in building design to
provide indoor air quality.

Green technology uses the principals of sustainability, risk/ hazard control and life
cycle impacts to develop new materials and processes. For example green technology
principles dictate that an updated and thorough systems analysis of building materials
would be conducted, including a cradle-to-cradle accounting of materials and energy
use of the facility. In carrying out such an analysis, all aspects of indoor air impacts
on human health would be included in a systematic manner. Furthermore green
building design should recognize, utilize and incorporate ways to adapt to future
technologies.

11

Buildings and illness

In discussing buildings and effect on health, two types of illnesses are considered:
building related-disease and non-specific building-related illness (NSBRI), sometimes called
sick building syndrome. NSBRI is a condition where individuals develop symptoms from a
build-up of irritants in the environment probably associated with poor ventilation. The
indoor air quality may affect multiple individuals who share the same environment. These
non-specific symptoms commonly include headache, drowsiness, and burning and irritation
of the eyes, nose and throat and sometimes cough. The offending substances can be
biological or chemical but generally are at a concentration too low to cause identifiable
disease, but at sufficient levels to cause mucous membrane irritation, respiratory symptoms,
central nervous system symptoms, and skin complaints. The illnesses usually resolve
without long-term consequences outside the environment, but not always immediately.
Building-related disease is a more severe condition. Clear diagnostic criteria and recognized
patho-physiology characterize building-related illnesses. Individual susceptibility is often a
factor. These conditions develop because of exposure to infective, toxic, irritant or
immunological agents in the buildings that trigger or exacerbate disease. Specific diseases
of identified concern with indoor air quality include: asthma, hypersensitivity pneumonitis;
sarcoidosis; rhinitis/sinusitis; laryngitis; and dermatitis (adapted from Center for Indoor
Environments and Health Guidance for Clinicians Course: Mold and Moisture
[Link]
Poisonings from inhaling specific chemicals such as carbon monoxide are recognized
as health risks associated with indoor exposures. However syndromes related to inhalation
of toxins from biological sources are not well defined and there is no consensus as to the
nature, patho-physiology or cause of these syndromes. Limitations in exposure assessmentdefining the route, mode and amount of exposure; and in separating building influences from
other (non-environmental) factors when assessing health impede efforts to understand
relationships of biological toxins with indoor air exposures. However, with an increasing
number of building occupants who attribute cognitive and neurological impairment to
exposure to biological (fungal in particular) toxins, the possibility of indoor environments
contributing to the risk should not be dismissed.

Green building certification

There is a growing reliance on voluntary building certification programs. Private
organizations offer certification programs that include training of practitioners in the
program. The American National Standards Institute recently certified one of the
commercially available programs (ANSI 2010). The certification programs proffer points
for specific building elements and design processes that impact a buildings performance.
Certification programs have been criticized for supporting building designs that could be
inadequate relative to indoor environment and health (Walsh 2010, Wargo 2010). The
programs vary in their indoor air quality requirements and in the flexibility that is allowed on
how a building may attain points. Depending on the choices that the design team makes, the
systems may unintentionally support building designs that are inadequate relative to indoor
air quality and health. For example, building designs that earn their green labels may or

12

may not adequately consider moisture and sources of bioaerosals- critical elements to
consider to sustain indoor air quality supportive of occupants health.
Improvements to certification programs to secure attention to indoor air quality might
address the following questions:

What elements should be mandatory? What priorities underlie prerequisite

actions and minimum point determinations? What criteria establish the priorities?
Is the tension between energy conservation and indoor air quality resolved
adequately? (Here is one example- Variable (based on occupancy) ventilation
control is an energy saving measure. However, in some climates, humidity
control (at least during some seasons) may be indicated irrespective of space use
to control biological amplification and bioaerosols. A means to address moisturepossibly decoupling dehumidification from temperature control- may be needed
in the heating, ventilation and air conditioning design to achieve quality indoor air
quality.)
How will construction be monitored in particular during operations critical to air
quality (such as roof membranes, material storage)?
Should building performance relative to indoor air quality criteria be monitored
before attaining certification? What measures? How long?
Are maintenance concerns (including impacts to maintenance staff) adequately
anticipated?
Are independent third party assessments cost-effective?
Should building and building systems commissioning be required?
Should certifications expire/ have to be renewed? What time frame?

Weatherization and retrofit construction

Weatherization programs seek to reduce air leakage in homes and raise heating
efficiency. Currently with support of stimulus funds, weatherization is encouraged with
assistance available to low income families (US Department of Energy Weatherization
Assistance Program). There are a number of indoor air quality considerations that should be
added to weatherization activities. Unintended, but not unlikely, consequences of tightening
the air flow in homes include an added potential for humidity with development of damp
areas and/or wet spots from condensation, and building up of air contaminants. Lead dust
contamination from leaded window replacement, if not removed correctly, will increase lead
exposure for the workers and possibly for the building occupants. Application of spray
polyurethane foam insulation material pose health risks to applicators in particular and
possibly to occupants if the material continues to emit troubling chemicals. Weatherization
assessments should anticipate these concerns and be coupled with resources that instruct
home owners on remedies for the possible/probable indoor air problems that may arise with
areas of dampness in the home and higher levels of contaminants (Richardson and Eick
2006).

13

Available guidance
Climate change has forced attention on buildings, as an opportunity for energy
savings, but also as an opportunity to use the tools and technologies to build structures well
suited for their anticipated use that increase value to society. The national priority for
energy efficiency is established; programs are in development or implementation; and with
current political and public will, energy efficiency and sustainability will continue to move
forward. Prioritizing occupant health adds complexity and some technical challenge. But
guidance is available. ASHRAE s Indoor Air Quality Guide; Best Practices for Design
Construction and Commissioning provides detailed information and is currently available
as a free download (ASHRAE 2009). The choice is to continue with programs as currently
defined with inadequate anticipation of occupant health risks from green building design
or integrate health- supporting environments into the definition of green buildings.

14

5. Recommendations and outlook on public health and health provider

roles
In our society, the public health and clinical communities are charged to foster our
quality of life by protecting and improving health. Public health practitioners address health
from a population viewpoint and although clinicians focus primarily on the health needs of
individuals, they assume public health responsibilities. Both groups have important roles in
responding to climate change. In this section, we suggest where leadership from public
health and health provider communities could act to address potential health impacts
associated with environmental exposures, especially with climate change adaptive measures
focused on energy conservation in buildings.

Green buildings and public health practice

Public health practitioners, especially with expertise in environment, bring a
perspective that has been missing in many of the architecture, construction and engineering
communities that have assumed leadership on green buildings. We suggest public health
involvement to:

Begin a process to establish minimum mandatory criteria on indoor air quality in

green buildings that includes: ventilation, moisture, radon resistance and
potential for emission of concerning chemicals.

Provide input on occupant health benefits and costs for use in development of
standard tools for assessing life cycle and economic impacts of building
performance.

Expand research to define the benefits and costs of health-supporting indoor

environments.

Participate in efforts that evaluate climate change mitigation and adaptation

measures and discuss the need to develop/add additional metrics to address indoor
environment and occupant health.

Explore applicability of environmental impact assessments (EIA) as a tool in

assessing green building design and develop a specific template for including
occupant health-supportive measures in the assessment. (Health Canada suggests
including climate change and health considerations in EIA).

Develop specific guidance for local and regional planning efforts on climate
change adaptation that 1) facilitates community participation, and 2) addresses the
threat of green buildings to indoor environmental quality and occupant health.

Engage building and housing agencies in development of appropriate minimum

codes and healthy homes programs

15

Develop programs and resources that serve to educate:

o the public on what measures they can take and how they can evaluate actions
that may have consequences to indoor air quality and their health;
o local health departments on working with state and municipal agencies
developing green building programs, and on responding to publics IAQ
concerns;
o healthcare practitioners on IAQ involvement in health; and
o emergency response workers on occupational exposures

Develop targeted training programs in collaboration with building scientists,

engineers, industrial hygienists and environmental experts for:
o building owners, architects, design teams and contractors;
o housing and institutional personnel;
o local and state public health staff, local and regional planners, and public
health responders; and
o green jobs workforce.
A chart identifying key components of the trainings for each of these groups is
presented in Appendix A.

Consider hosting a nationwide clearinghouse for surveillance information on

health outcomes from indoor exposures

Surveillance, sentinel case model and prevention

Climate change is a gradual ongoing process over time. Consequently, one would not
expect to see a sudden change in the health status of the population, but a gradual adverse
effect of the same diseases that are currently attributable to the current environment,
especially the indoor environment. These would include a gradual increase in a number of
environmentally related diseases over time, especially respiratory diseases such as asthma,
chronic obstructive lung disease and hypersensitivity pneumonitis.
These gradual health changes due to climate phenomenon are not going to be
recognized unless one is first aware that it may occur, and then to take specific steps to
identify the cause. Surveillance, sentinel case definition and identification, and prevention
need to be the mainstay of the public health and medical communities. The diagnosis of an
individual with a sentinel illness associated with exposures in a particular environment
may indicate that these exposures may also deleteriously act on others. Intervention in the
environment to limit identified exposures is an opportunity for primary prevention. Public
health surveillance systems currently in place for a number of diseases need to be expanded.
Environmental public health tracking efforts that consider both large scale (climate data) and
small scale (specifics of indoor environments) information could be used in incidence and
prevalence studies.
Physicians and laboratories- clinical and environmental- must be made aware of and
report any sentinel case that may lead to a cluster of illness in a specific building or
community. Educational programs on climate change-driven indoor exposures and
population healthcare needs should be available to individual and group physicians. The
16

public needs to become educated as to changes that they can make to the indoor environment
to prevent building-related illnesses.

Health information technology

Health information technology (IT) is thought to be a mandatory component to
successful healthcare reform. American Recovery and Reinvestment Act (ARRA), through
the Acts Health Information Technology for Electronic and Clinical Health provisions
allocated billions of dollars, mostly for incentives to accelerate electronic health record
development. Healthcare reform is relying on assumed efficiencies created from health IT.
This advantage is expected to accrue not only from improved processing of medical benefits
but also from improved health outcomes. The intention is that this investment in health IT
should improve health surveillance and analysis, management and decision support (DeBor
and Wah 2010).
Choosing which data to collect in electronic records is critical to the utility of the IT
system. In the clinical setting, environmental contributors to health would be addressed
with the patients medical history. However in todays time-stressed primary care setting,
this topic is generally given inadequate attention. Providers confronted with more specific
health concerns and others in specialty fields such as allergy and occupational medicine are
more likely to explore environment, but possibly not the subtleties of indoor exposures. If
current IT efforts to establish a universal/or recommended template for electronic health
record are successful, public health leadership is needed now to influence inclusion of
information that reveals environmental exposures in the home, school, office and work
environments. Incorporating geo-coding into health records may be reasonable. If
accomplished this could contribute to surveillance efforts to establish a potent database on
indoor environments and health. Moreover it would be advantageous to have health and
associated environmental data in the same system.
Coupled with collecting information, efforts are needed to develop decision support
models to utilize these data both in clinical care and public health practice. Algorithms
using the information could be developed to guide providers to improve individual clinical
care. In situations where exposures indoors play a role in illness, data from electronic health
systems that include health information and environmental characterization would allow
integration of environmental intervention into medical treatment, an element that would work
to improve health outcome. Other decision support models utilizing a pool of information
without personal identifiers could support healthy housing and healthy workplace public
health initiatives. As Knowlton demonstrated in his assessment of the 2006 heat wave,
surveillance data (limited to emergency department and hospital utilization records) can be a
tool in understanding the health impacts of catastrophic climate events and in suggesting
appropriate public health planning responses (Knowlton et al. 2009). With our concern over
climate change and possible consequences from energy efficient buildings, decision models
could be developed collaboratively with public health professionals, clinicians, building
scientists and engineers to respond to the implications of energy conservation to occupant
health.

17

Access to sensitive and vulnerable groups through community health centers

Community health clinics (CHC) have been significant beneficiaries of ARRA, with
$2 billion directly allocated in 2009 and 2010 for new sites and infrastructure. CHC are a
critical part of the healthcare safety net for the poor and/or uninsured populations
(California Healthcare Foundation 2009). School based health centers also provide safety
net health care to poor children in urban and rural schools (Mansour et al. 2008). CHC,
given resources and care management decision tools, respond well to the health needs of
some of our most vulnerable population. Of interest to indoor air quality, use of asthma
management plans, an important tool in addressing environmental contributors to the disease,
substantially increased after implementation of a decision support model (Hicks at al. 2006,
Landon et al. 2007). In this way, CHC are positioned to provide care and (with support from
academic health centers (Markuns et al. 2009)) education to targeted communities on how to
make their indoor environments health-supporting. CHC may also be in a unique position to
engage the community in local response planning for climate change adaptation. Other
associated initiatives such as healthy homes programs could be integrated into CHC and
clinic care portfolios.

Clinicians public health leadership

Preventive measures for respiratory and other environmentally related disease should
place special emphasis on control of indoor air quality. This becomes especially relevant
considering that these effects could be exacerbated by climate change. The following list of
activities suggested for health providers builds on recommendations of various medical
societies, and the previous discussion.
Leadership from clinicians is suggested to:

18

actively support policy directed to climate change mitigation and adaptation

efforts (Martens et al. 1997.)

take individual responsibility in addressing climate change and become examples

for the community. [Nurses are encouraged to adopt individual behaviors- such
as purchasing energy-efficient appliances and cars, recycling in the workplace and
joining community groups (Afzal 2007). Similarly, a physician continuing
education module from the American College of Preventive Medicine (ACPM)
identifies recommendations for health professionals to reduce their personal
contributions to climate change (Brenner and Parker 2009)];

increase personal awareness and understanding of the environmental issues so to

provide improved care. [Practice suggestions for allergists treating patients
seeking advice on indoor air quality specifically suggest consideration of
environmental factors that include indoor air quality monitoring methods,
interpreting data, and familiarity with healthy homes(Bernstein et al. 2008.)
ACPM surveyed their membership on environmental health and found that
members spent little time with patients on climate change, hazards found in the
home and other indoor environments, or issues related to general environmental

health. The organization is offering a series of educational webinars on indoor air

quality (ACPM 2008)];

engage in professional medical society activities that develop policy and practice
guidelines so to increase attention on health effects from indoor environmental
exposures and intervention in indoor environment as part of overall disease
prevention. [This would serve to expand awareness of climate change health
consequences from indoor exposures. For example, the American Academy of
Pediatrics published a comprehensive paper on climate change and childrens
health supporting a wide range of climate change mitigation measures including
green buildings (Shea et al. 2007). A companion discussion on risks to
respiratory health and asthma in children who occupy homes with energy efficient
measures where indoor air quality was not addressed adequately (Richardson and
Eick 2006) would add t guidance for pediatricians.]

in collaboration with public health leadership:

o advocate for inclusion of specific information on environmental
contributors to disease in development of electronic medical records and
public health survey instruments including National Health and Nutrition
Examination Survey, and the Behavioral Risk Factor Surveillance System;
and
o develop a needs assessment and strategy for CHC community engagement
on indoor environments.

develop support for medical education including curricula for undergraduate

programs, elective internships and continuing medical education that address
climate change and indoor exposures.

19

6. Conclusions
Reducing green house gas emissions with changes in energy production and use
patterns is expected to accrue substantial benefits to public health through improvements in
air pollution, reduced occupational hazards, and reduced occurrence of large scale accidents
(i.e. oil spills) that is expected to accompany a shift away from reliance on fossil fuel (Smith
and Haigler 2008, Levy et al. 2003). In this era of concern and response to climate change,
this paper sought to address indoor environments to identify and bring into the discussion
possible threats/unintended risks to the health of building occupants from well-intended
climate change adaptive measures.
Health consequences to occupants of buildings with poor indoor air quality can be
substantial (Mudarri and Fisk 2007). Some agents of concern in the indoor environment are
moisture and associated biota, and a number of chemicals and gaseous materials. Public
health leadership will support our countrys transition to more energy-efficient buildings.
While recognizing the critical need to reduce energy burden in buildings, public health also
has the perspective to bring indoor environmental quality and occupant health into the dialog
and decisions about green buildings. With developing health IT and treatment models,
public health leadership within medicine is in a unique position to suggest and support
measures focused on environmental determinants of health.
Moving the countrys building stock to green buildings energy efficient,
environmentally sustainable, occupant health-supporting and current with green
technologies- is an important climate change adaptive strategy. Indoor environments
supportive of occupant health is critical to illness prevention and the well being of our
communities. The largest burden of not anticipating the potential for unintended negative
consequences to indoor air quality from energy efficiency would likely be born by the most
sensitive and vulnerable in our communities. The need isnt to choose between
improvements in energy efficiency and indoor air quality, but rather to improve upon the
current approach to green buildings to avoid adding health risk from indoor exposures. This
paper identifies some concerns, suggests some actions and notes some timely opportunities
for leadership and involvement in an effort to aid the needed discussion.

20

7. References
Afzal B M. Global warming: A public health concern. OJIN American Nurses Association 2007.
12(2.5).
[Link]
Contents/Volume122007/No2May07/[Link]
American College of Preventive Medicine (ACPM). Membership Environmental Health Education
Needs Assessment 2008. [Link]
Indoor Air Quality Initiative [Link]
American Lung Association (ALA). Global warming impacts to public health and air quality 2007.
[Link]
American National Standards Institute (ANSI). ANSI/GBI 01-2010- Green Building Assessment
Protocol for Commercial Building. 2010. [Link]
American Society of Heating, Refrigerating and Air Conditioning Engineers (ASHRAE). Indoor Air
Quality Guide: Best Practices for Design, Construction, and Commissioning 2009.
[Link]
Architecture 2030. The building sector: A hidden culprit; A historic opportunity.
[Link]
Blanger D, Gosselin P, Valois P, Abdous B. Use of residential wood heating in a context of climate
change: a population survey in Quebec Canada BMC Public Health 2008. 8:184.
Bernstein JA, Alexis N, Bacchus H, Bernstein IL, Fritz P, Horner E, Li N, Mason S, Nel A, Oullette
J, Reijula K, Reponen T, Seltzer J, Smith A, Tarlo SM. The health effects of non-industrial indoor air
pollution. J Allergy Clin Immunol 2008. 121(3):585-91. Epub 2007 Dec 21.
Bernstein T. Municipal green building policies: Strategies for transforming building practices in the
private sector. Environmental Law Institute 2008.
[Link]
Bernstein T, Lamb Z. Building healthy, high performance schools: A review of selected state and
local initiatives. Environmental Law Institute 2003.
[Link]
Bhaskaran K, Hajat S, Haines A, Herrett E, Wilkinson P, Smeeth L. Effects of ambient temperature
on the incidence of myocardial infarction. Heart 2009. 95(21)1760-9.
Brenner SA, Parker CL. Health effects of global climate change: How health professionals can be
part of the solution. Medscape CME Public Health and Prevention. American College of Preventive
Medicine 2009. [Link]

21

California Healthcare Foundation. The impact of federal stimulus funds on community health centers
in California July 2009 Issue Brief
[Link]
Centers for Disease Control and Prevention (CDC). Health concerns associated with mold in waterdamaged homes after hurricanes Katrina and Rita-New Orleans area, Louisiana, October 2005.
Morbidity and Mortality Weekly Report 2006. 55(2):41-4.
Confalonieri UB, Menne R, Akhtar KL, Ebi M, Hauengue RS, Kovats B, Revich, Woodward A,
2007: Human Health. Climate Change 2007. Impacts, Adaptation and Vulnerability. Contribution of
Working Group II to the Fourth Assessment Report of the Intergovernmental Panel on Climate
Change, ML Parry, OF Canziani, JP Palutikof, PJ van der Linden and CE Hanson, Eds., Cambridge
University Press, Cambridge, UK, 391-431.
[Link]
Cox-Ganser JM, Rao CY, Park J-H, Schumpert JC, Kreiss K.
Asthma and respiratory symptoms in hospital workers related to dampness and biological
contaminants. Indoor Air 2009. 19(4): 280-290.
DeBor G, Wah R. Health-care reform, stimulus funds will benefit health IT. Health and Community
Services March 1 2010. Government Technology Digital Communities
[Link]
Dherani M, Pope D, Mascarenhas M, Smith KR, Weber N, Bruce N. Indoor air pollution from
unprocessed solid fuel use and pneumonia risk in children aged under five years: a systematic review
and meta-analysis. Bulletin of the World Health Organization 2008; 86(5):390-8.
Field RW, Steck DJ, Smith BJ, Brus CP, Fisher EL, Neuberger JS. Platz CE, Robinson RA, Woolson
RF, Lynch CF. Residential radon gas exposure and lung cancer. American Journal of Epidemiology
2000. 151(11):1092-1102.
Gauderman WJ, Avol E, Gilliland F, Vora H, Thomas D, Berhane K, McConnell R, Kuenzli N,
Lurmann F, Rappaport E, Margolis H, Bates D, Peters J. The effect of air pollution on lung
development from 10 to 18 years of age. N Engl J Med. 2004. 351(11):1057-67.
Health Canada. Adapting to the Health Effects of Climate Change 2009 [Link]
Helgeson JF, Lippiatt BC. Multidisciplinary life cycle metrics and tools for green buildings, abstract
only. Integr Environ Assess Manag. 2009. 5(3):390-8.
Hicks LS, O'Malley AJ, Lieu TA, Keegan T, Cook NL, McNeil BJ, Landon BE, Guadagnoli E. The
quality of chronic disease care in U.S. community health centers. Health Affairs (Millwood) 2006.
25(6):1712-23.
Institute of Medicine (IOM). Damp Indoor Spaces and Health. 2004 National Academies of
Sciences Press. [Link]

22

Josseran L, Caillre N, Brun-Ney D, Rottner J, Filleul L, Brucker G, Astagneau P. Syndromic

surveillance and heat wave morbidity: A pilot study based on emergency departments in France.
BMC Medical Informatics and Decision Making 2009. 9:14.
Knowlton K, Rotkin-Ellman M, King G, Margolis HG, Smith D, Solomon G, Trent R, English P. The
2006 California heat wave: Impacts on hospitalizations and emergency department visits.
Environmental Health Perspectives. 2009. 117(1):61-7. E. Pub 2008
Knzli N, Avol E, Wu J, Gauderman WJ, Rappaport E, Millstein J, Bennion J, McConnell R,
Gilliland FD, Berhane K, Lurmann F, Winer A, Peters JM. Health effects of the 2003 Southern
California wildfires on children. Am J Respir Crit Care Med. 2006. 174(11):1221-8. Epub 2006 Aug
31.
Landon BE, Hicks LS, O'Malley AJ, Lieu TA, Keegan T, McNeil BJ, Guadagnoli E.
Improving the management of chronic disease at community health centers.
N Engl J Med. 2007. 356(9):921-34.
Langrish JP, Mills NL, Newby DE. Heat and haze: a forecast for myocardial infarction? Heart 2009.
95:1721-2. Epub 2009 Aug 16.
Levy JI, Nishioka Y, Spengler JD. The public health benefits of insulation retrofits in existing
housing in the United States. Environmental Health: A Global Access Science Source 2003, 2:4
[Link]
Markuns JF, Culpepper L, Halpin WJ Jr. Commentary: A need for leadership in primary health care
for the underserved: A call to action. Acad Med. 2009. 84(10):1325-7.
Martens WJ, Slooff R, Jackson EK. Climate change, human health, and sustainable development.
Bulletin of the World Health Organization 1997. 75(6):583-8.
McDonald JW, Alvarez F, Keller CA. Pulmonary alveolar proteinosis in association with household
exposure to fibrous insulation material. Chest 2000. 117(6):1813-17.
Morey P R. Climate change and potential effects on microbial air quality in the built environment,
Preliminary draft 2010. [Link]
Mudarri D. Fisk WJ. Public health and economic impact of dampness and mold. Indoor Air 2007.
17(3):226-35.
Mudarri D. Public health consequences and cost of climate change impacts on indoor environments.
2010 [Link]/iaq/pdfs/[Link]
Park JH, Cox-Ganser JM, Kreiss K, White SK, Rao CY. Hydrophilic fungi and ergosterol associated
with respiratory illness in a water-damaged building.
Environmental Health Perspectives. 2008 116(1):45-50.
Petrosyan V. von Braun MC. Spalinger [Link] Lindern IH. Seasonal variations of lead
concentration and loading rates in residential house dust in northern Idaho. Journal of Hazardous
Materials 2006. 132:68-79. Epub 2006

23

Portier CJ, Thigpen Tart K, Carter SR, Dilworth CH, Grambsch AE, Gohlke J, Hess J, Howard SN,
Luber G, Lutz JT, Maslak T, Prudent N, Radtke M, Rosenthal JP, Rowles T, Sandifer PA, Scheraga J,
Schramm PJ, Strickman D, Trtanj JM, Whung P-Y. A Human Health Perspective On Climate
Change: A Report Outlining the Research Needs on the Human Health Effects of Climate Change.
2010. Environmental Health Perspectives/National Institute of Environmental Health Sciences.
[Link]/climatereport
Richardson G, Eick SA. The paradox of an energy-efficient home: Is it good or bad for health?
Community Practitioner 2006. 79(12):397-9.
Schulte PA, Chun H. Climate change and occupational safety and health: Establishing a preliminary
framework. Journal of Occupational and Environmental Hygiene 2009. 6(9):542-54.
Shea KM. American Academy of Pediatrics Committee on Environmental Health. Global climate
change and children's health. Pediatrics 2007.120(5)e1359-e1367 Epub 2007
[Link]
Smith KR, Haigler E. Co-benefits of climate mitigation and health protection in energy systems:
Scoping methods. Annu. Rev. Public Health 2008. 29:1125.
Storey E, Dangman KD, Schenck P, DeBernardo RL, Yang CS, Bracker A, Hodgson MJ. Guidance
for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and
Moisture Indoors. University of Connecticut Health Center 2004.
[Link]
US Department of Energy (DOE). Energy Efficiency and Renewable Energy
Weatherization & Intergovernmental Program, Weatherization Assistance Program.
[Link]
US Department of Housing and Urban Development. Leading Our Nation to Healthier Homes, The
Healthy Homes Strategic Plan 2009.
[Link]/offices/lead/library/hhi/hh_strategic_plan.pdf
US Environmental Protection Agency (EPA). Building Codes for Energy Efficiency
[Link]
US Environmental Protection Agency (EPA). National Action Plan for Energy Efficiency
[Link]
US Environmental Protection Agency (EPA). Buildings and the Environment: A Statistical Summary
2009. [Link]/greenbuilding/pubs/[Link]
US Environmental Protection Agency (EPA). Green Buildings Frequent Questions
[Link]
US Environmental Protection Agency (EPA). Indoor airPLUS Construction Specifications. EPA
402/K-08/003, January 2009. [Link]
US Environmental Protection Agency (EPA). EPA Assessment of Risks from Radon Homes. EPA
402/R-03-003, June 2003 [Link]

24

US Global Change Research Program. Global Climate Change Impacts in the United States. TR
Karl, JM Melillo, TC Peterson eds. Cambridge University Press 2009.
[Link]
Wade TJ, Mansour ME, Guo JJ, Huentelmann T, Line K, Keller KN. Access and utilization patterns
of school-based health centers at urban and rural elementary and middle schools, abstract. Public
Health Reports 2008. 123(6):739-50.
Wallack J. and Ramanathan V. The other climate changers, why black carbon and ozone also matter,
essay. Foreign Affairs 2009. 88 (5): 105-13. [Link]
Walsh D. Green building: How to put the IH in LEED. The Synergist Magazine April 2010.
American Industrial Hygiene Association.
Wargo J. LEED Certification: Where Energy Efficiency Collides with Human Health. Environment &
Human Health, Inc. 2010. [Link]
Washington State Department of Ecology. Health Effects of Wood Smoke. 1997.
[Link]
Weschler CJ. Ozones impact on public health: Contributions from indoor exposures to ozone and
products of ozone-initiated chemistry. Environmental Health Perspectives 2006. 114(10).
Wisthaler A, Weschler CJ. Reactions of ozone with human skin lipids: sources of carbonyls,
dicarbonyls, and hydroxycarbonyls in indoor air. Proc Natl Acad Sci U S A. 2010. 107(15):6568-75.
Epub 2009.
World Health Organization (WHO). Guidelines for Indoor Air Quality-Dampness and Mould. 2009.
[Link]

25

26

Appendix A: Trainings for professional communities on buildings and health

A.1 Target Audience: Building owners, Architects, Design teams, Contractors
Training Topics

Moisture control in
the built
environment

Link to climate change and the

indoor environment

Increased flooding, more

extreme weather
Inadequate humidity control

Designing heating,
ventilating and air
conditioning
(HVAC) systems for
offices and homes

Increase in outdoor temperature,

increased concentrations of
outdoor allergens, tighter
buildings- demand for HVAC
increases. Improperly designed
or maintained HVAC can
contribute to poor IAQinadequate dilution and/or
humidity control, microbial
reservoirs.

Key components of trainings

How to: design buildings that have

appropriate drainage, vapor barriers and
flashing; and select appropriate and
properly sized heating ventilation and air
conditioning (HVAC) systems that
control humidity (see next item).
Elements for maintenance plan including
leak repair and HVAC maintenance.
Available resources.

How to design HVAC systems for the

built environment that address the
multiple goals of providing outside air,
thermal comfort, humidity control and
filtration. The curriculum should
highlight moisture control issues- sloped
drain pans, avoid internal duct lining,
easy access throughout HVAC system.
Available resources.

Designing radon
Tighter buildings may lead to an
remediation systems increase in indoor radon
concentrations.

How to assess need for radon mitigation

How to design radon remediation systems
to ventilate radon gas in the built
environment.
Radon-resistant homes-EPA program.

Energy efficient
power generation

Regional and local benefits of

incorporating wind, solar, geothermal into
building design.

Buildings increasingly will use

energy efficient sources of
power. Positive for the indoor
environment- less costly to bring
in outside air, decreased
exposure to combustion products
from traditional energy sources.

27

Appendix A: Trainings for professional communities on buildings and health

A.1 Target Audience: Building owners, Architects, Design teams, Contractors
Training Topics

Link to climate change and the

indoor environment

Key components of trainings

Prevention by
design

The construction of green

buildings that are more energy
efficient and use renewable
energy sources should reduce
occupant exposure to volatile
organic compounds (VOC)
associated with traditional
building materials.

How to design buildings with appropriate

moisture control, HVAC systems and
energy efficient power.
How to select building materials
(insulation, coatings, flooring).
Emphasize the importance of reviewing
the health hazards of environmentally
safer materials before use.
Limitations, pros and cons of: preoccupancy time for off-gassing; and long
term monitoring.

Indoor air quality

(IAQ) components
of building
certification
program

Building certification programs

provide architects and building
owners with valuable incentives.
Energy efficiency endpoints are
emphasized. Understanding the
process and possible IAQ
endpoints should encourage
improved building design.

Emphasize current IAQ management plan

endpoints: moisture control, drainage,
ductwork protection, HVAC production,
use of low VOC building materials,
minimum ventilation etc.

Public transportation Decrease in entrainment of

idling vehicle combustion
products

Importance of locating buildings near

public transportation and bike paths.

Weatherization

Potential effects of weatherization

construction on indoor environmental
quality.
How to minimize emissions (e.g.: lead
(window replacement); fibers (ventilation
and insulation activities); and foam
(insulation activities).
How to determine appropriate
weatherization goals.
Available resources.

Weatherization programs for

homes and commercial buildings
may result in areas in the
structure with inadequate
ventilation, humidity, and/or
unhealthy concentrations of
irritants in the air.

28

Appendix A: Trainings for professional communities on buildings and health

A. 2 Target Audience: Housing and Institutional Facility Personnel

Training Topics

Link to climate change and the

indoor environment

Key components of trainings

Cleaning and
disinfection

Tighter buildings may lead to an

increase in indoor VOC and
irritants. Improved cleaning
practices and utilizing safer
alternatives will improve indoor
air quality (IAQ).

Selection of environmentally preferable

cleaning products (green cleaners).
Knowledge of third party certified labeling
and EPA Design for the Environment
programs; best practice cleaning methods;
proper use of sanitizers and disinfectants;
and appropriate materials and equipment.

Green purchasing

Tighter buildings may lead to an

increase in indoor volatile
organic compounds (VOC),
respiratory irritants, lead dust.
Improved cleaning practices and
utilizing safer alternatives will
improve IAQ.

How to evaluate and select

environmentally preferable furnishings,
flooring, paints etc.

Ventilation
maintenance

Increase in outdoor temperature,

increased concentrations of
outdoor allergens, tighter
buildings- demand for HVAC
increases. Improperly
maintained HVAC can
contribute to poor IAQinadequate dilution, microbial
reservoirs.

HVAC systems and moisture control.

Importance of drain pan maintenance.
Importance of humidity control throughout
the calendar year.
Selection of appropriate filters.
Duct cleaning (pros and cons, criteria).

Mold abatement and Tighter homes may create areas

moisture control
conducive to condensation.
Increased flooding, more
extreme weather.

Clean up practices after a flood or moisture

incursion; including safe use of generators
and other powered equipment.
Worker protection.

29

Appendix A: Trainings for professional communities on buildings and health

A. 2 Target Audience: Housing and Institutional Facility Personnel
Training Topics

Link to climate change and the

indoor environment

Key components of trainings

Energy efficient
power maintenance

Buildings increasingly will use

energy efficient sources of
power. Positive for the indoor
environment- less costly to bring
in outside air, decreased
exposure to combustion products
from traditional energy sources.

How to maintain new energy efficient

power equipment, e.g.: solar, wind,
geothermal, fuel cells, others.

Integrated pest
management (IPM)

Increased moisture/flooding
could lead to increased problems
with pests.

Detailed IPM training

Moisture control and alternatives to
pesticides.

Radon

Tighter buildings may lead to an

increase in indoor radon
concentrations. Construction
activities that disturb basement
may affect radon exposure.

When and how to test for radon.

How to maintain radon mitigation systems.
Available resources.

Weatherization

Weatherization programs for

homes and commercial buildings
may result in areas in the
structure with inadequate
ventilation, humidity, and/or
unhealthy concentrations of
irritants in the air

Potential effects of weatherization

construction on indoor environmental
quality.
How to minimize emissions (e.g.: lead
(window replacement); fibers (ventilation
and insulation activities); and foam
(insulation activities).
How to determine appropriate
weatherization goals.
Available resources.

30

Appendix A: Trainings for professional communities on buildings and health

A.3 Target Audience: Public Health Personnel, Public Health Responders, Local and Regional
Planners, Clinicians
Training Topics

Link to climate change and the

indoor environment

Public health
training on indoor
environments and
occupant health
targeted to specific
population needs

Populations susceptible to
elevated temperature: obese,
elderly, people with
hypertension, thyroid disease,
cardiovascular disease, chronic
respiratory disease.
Green buildings and/or
weatherized buildings where
IAQ was inadequately
addressed.

Recognition of
environmental or
occupational illness
associated with the
built environment

Nonspecific
symptoms/syndromes and
building-related illnesses
including: asthma,
hypersensitivity pneumonitis,
heat stress, dermatitis, cancer
(radon), etc.

Key components of trainings

Attention to risk factors: Dehydration,

weight loss etc.
Information from local and regional plans:
including cool shelters, effective
messages.
Use of combustion sources-stoves.
Resources available to general public on
indoor air problems including potential
moisture and concentration of pollutants
from tighter homes.

Consideration of environmental exposures

integrated with clinic visits
Environmental and occupational history
taking.
Diagnosis of building-related disease
Medical management and control
strategies.
Illness prevention approaches including
the sentinel case model.
Physician reporting and disease
surveillance.

31

Appendix A: Trainings for professional communities on buildings and health

A.4 Target Audience: The workforce involved in the Green Jobs created in response to
climate change
Training Topics

Link to climate change and the

indoor environment

Building
weatherization

Buildings will need to be more

energy efficient

Health and Safety: Disposal of broken

compact fluorescent lights (mercury);
insulation removal (mold, fiberglass);
safety of new foam insulation (chemical
emissions) and new caulking materials.

Installing and
maintaining energy
efficient equipment

Buildings increasingly will use

energy efficient sources of
power.

Health and safety issues associated with

the installation or maintenance of
geothermal systems, high efficiency heat
pumps, solar hot water heaters, solar array
installations.
Potential inhalation hazards associated
with new refrigerants.
Confined space entry; slips and falls from
heights.

Flood cleanup and

mold abatement

Increased flooding, more

extreme weather

Health and safety issues associated with

exposure to mold contaminated areas and
carbon monoxide (internal combustion
engines used indoors), electrical hazards,
infections.
Pros and cons of available approaches to
abatement

Cleaning and
disinfection

Tighter buildings will lead to an

increase in indoor VOC and
irritants. Improved cleaning
practices and utilizing safer
alternatives will improve IAQ

Many green cleaning products have been

screened for environmental safety, not
worker safety. Importance of selecting
third party certified products that insure
that the product does not contain known
respiratory sensitizers (Association of
Occupational and Environmental Clinics
list);
Best practice cleaning methods,
appropriate materials and equipment

Key components of trainings

32