Appendix B
Building-Related Symptoms

People spend far more time indoors than outdoors—on average, more than 90% (Nelson et al. 1994). However, regulatory standards for environmental health hazards, other than those in the workplace,1 focus on the outdoor environment. The unregulated indoor environment includes homes, schools, commercial spaces (e.g., shopping malls), recreation areas, and highly specialized settings such as aircraft cabins.

Aircraft cabins have environmental problems similar to those of modern offices. Both aircraft and office buildings attempt to balance energy efficiency with other needs such as adequate ventilation, clean air, and acceptable temperature and humidity levels. Office buildings and aircraft may achieve the goal of energy efficiency by decreasing the amount of outside air drawn into the ventilation system. If the ventilation rate for outside air is reduced, and the outside air is mixed with recirculated air, this can result in elevated concentrations of carbon dioxide (CO2), volatile organic compounds (VOCs), and odors from internal sources such as cabin or building occupants. Chemical contaminants in outdoor air (e.g., motor vehicle exhaust) may enter a building. Contaminants may also originate from indoor sources, such as carpeting, adhesives, upholstery, wood paneling, office machines, cleaning agents, combustion prod-

1  

With recognition of BRS as an occupational health concern, the Occupational Safety and Health Administration proposed a set of rules for workplace environments on the basis that “…air contamination and other air-quality factors can act to present a significant risk of material impairment to employees working in indoor environments” (Fed. Regist 59:15969).



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The Airliner Cabin Environment and the Health of Passengers and Crew Appendix B Building-Related Symptoms People spend far more time indoors than outdoors—on average, more than 90% (Nelson et al. 1994). However, regulatory standards for environmental health hazards, other than those in the workplace,1 focus on the outdoor environment. The unregulated indoor environment includes homes, schools, commercial spaces (e.g., shopping malls), recreation areas, and highly specialized settings such as aircraft cabins. Aircraft cabins have environmental problems similar to those of modern offices. Both aircraft and office buildings attempt to balance energy efficiency with other needs such as adequate ventilation, clean air, and acceptable temperature and humidity levels. Office buildings and aircraft may achieve the goal of energy efficiency by decreasing the amount of outside air drawn into the ventilation system. If the ventilation rate for outside air is reduced, and the outside air is mixed with recirculated air, this can result in elevated concentrations of carbon dioxide (CO2), volatile organic compounds (VOCs), and odors from internal sources such as cabin or building occupants. Chemical contaminants in outdoor air (e.g., motor vehicle exhaust) may enter a building. Contaminants may also originate from indoor sources, such as carpeting, adhesives, upholstery, wood paneling, office machines, cleaning agents, combustion prod- 1   With recognition of BRS as an occupational health concern, the Occupational Safety and Health Administration proposed a set of rules for workplace environments on the basis that “…air contamination and other air-quality factors can act to present a significant risk of material impairment to employees working in indoor environments” (Fed. Regist 59:15969).

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The Airliner Cabin Environment and the Health of Passengers and Crew ucts, and biological contaminants. VOCs may be emitted from construction materials such as wall panels, furniture, and office equipment (e.g., computers, printers, copiers, and fax machines). In the aircraft cabin, VOCs may come from internal sources (e.g., passengers, their belongings, aircraft component materials, cleaning materials) or enter the cabin in the bleed air (see Chapter 3). In addition to VOCs, contamination by bacteria, viruses, and fungi is another persistent challenge to indoor air quality. Office buildings provide many opportunities for microbial growth such as faulty or inadequately maintained air-circulation systems, and bioaerosols emitted by occupants. Chapter 4 discusses microbial contamination in aircraft. Although office buildings and passenger cabins have very different external environments, the building environment may be a valuable research model for studying cabin air quality. In the sections below, some characteristics of building-related symptoms (BRS) that may provide information on aircraft cabin air quality are described. CHARACTERIZATION OF BUILDING-RELATED SYMPTOMS In buildings, the combination of reduced ventilation and contaminant emissions can result in serious costly, unexpected, and often unexplained health complaints by building occupants. Those complaints may arise with the installation of new office equipment or when people move into a space. BRS is a term applied to a group of complaints from a substantial number of employees or residents. This term replaces the widely used term sick-building syndrome. BRS is used to describe nonspecific symptoms (e.g., eye, nose, or throat irritation, headache, fatigue, or other discomfort) that cannot be associated with a well-defined cause but that appear to be linked to time spent in particular buildings. Although poorly defined, BRS is distinct from building-related illnesses, which are diagnosable diseases that can be directly attributed to specific indoor exposures (Menzies et al. 1995; Hedge 1995; Hodgson 1995; Menzies and Bourbeau 1997). BRS can be uncomfortable, even disabling, but permanent sequelae are rare (Redlich et al. 1997). Although there are several physiological markers for eye and mucosal effects, objective physiological abnormalities generally are not found. BRS is characterized by the following attributes: Most complaints can be categorized as neurobehavioral disruption (e.g., impaired memory), sensory irritation (especially eye, nose, and throat),

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The Airliner Cabin Environment and the Health of Passengers and Crew skin irritation, unspecific hypersensitivity reactions, and aberrant odor and taste sensations. Lower airway or internal organ symptoms are infrequent. More symptoms are reported in one building or a part of one building than elsewhere. Symptoms resolve shortly after leaving the building. INVESTIGATIONS OF BRS Investigations of BRS have focused on describing or solving a particular situation, although some have more general applicability. The California Healthy Building Study examined relationships between employee health complaints and several building, workspace, job, and personal factors (Mendell et al. 1996). Most complaints (40.3%) were of eye, nose, or throat irritation. Other complaints included fatigue and sleepiness (33.2%), headache (19.8%), dry and itchy skin (10.8%), chest tightness (7.5%), and chills and fever (4.5%). Among the 12 buildings surveyed, the prevalence of complaint differed. Occupants of the mechanically ventilated and air-conditioned buildings reported more symptoms than those of naturally ventilated buildings. Carpeting, carbonless-copy paper (which emits VOCs), and photocopiers seemed to be substantial contributors. Nonchemical factors, such as space sharing and distance from a window, also seemed to increase complaint prevalence. Elevated CO2 derived from occupant respiration and bioeffluents appears to be an important contributor to complaints of BRS. A review of BRS studies encompassing about 30,000 subjects (Seppänen et al. 1999) indicated a progressive reduction in symptoms as CO2 concentrations were reduced to below 800 ppm. Apte et al. (2000) analyzed the correlation between indoor CO2 concentrations and BRS symptoms in 41 office buildings. They relied on two measures: the daily average and the peak (1-h) differences between indoor and outdoor CO2 concentrations. Statistical analyses were conducted by categorizing BRS complaints into mucous membrane or chest and breathing difficulties. These analyses demonstrated a significant dose-response relationship between indoor CO2 and the incidence of BRS symptoms involving mucous membrane irritation, chest tightness, and wheezing. As CO2 concentrations decreased below 800 ppm, complaints also decreased. The authors emphasized that CO2 is an indicator of the building ventilation rate and not necessarily a direct cause of BRS. Although many reports of BRS and remediation measures are available,

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The Airliner Cabin Environment and the Health of Passengers and Crew almost no experimental data exist on the relationship between contaminant types and occupant complaints. In one experiment by U.S. Environmental Protection Agency (Otto et al. 1990), investigators synthesized a mixture of 22 VOCs and exposed volunteers at 25 mg/m3 of the mixture or to clean air. During a 240-minute exposure (longer than most domestic flights but shorter than most overseas flights), the volunteers reported increasing discomfort (irritation of eyes, nose, and throat) whether exposed to air or VOCs; however, the discomfort ratings were greater with exposure to VOCs at all times. Although a brief conventional, neuropsychological test battery revealed no significant performance deficits, a prolonged performance assay might offer a more suitable criterion for assessing such potential deficits. The sleep deprivation literature indicates that tests of longer duration are more sensitive to environmental disruption than those of shorter duration. Such an approach was used by Wargocki and coworkers (2000), who recruited 30 females (five groups of six each) to perform simulated office work for 4.6 hours under outdoor flow rates of 3,10, or 30 L/s per person. The performance measures included text typing, addition, proof-reading, and writing down alternative uses for common objects, which was designed to measure creative thinking. Six subjective measures were also assessed: air quality, odor intensity, eye-nose-throat irritation, environmental conditions (e.g., humidity), recognized BRS symptoms, and effort required to perform tasks. Simulated work performance, BRS complaints, and rated air quality all improved significantly with increased ventilation. ANALOGIES WITH PASSENGER AIR CABINS The committee recognizes that there are differences between the physical structures and operations of buildings and aircraft; however, they are both enclosed spaces occupied by people. Therefore, the committee decided that it was appropriate to discuss below some of the studies of responses of cabin crews and passengers to cabin air quality and compares them to studies on building occupants. The committee also compares contaminant concentrations in aircraft and buildings. Cabin Crew Unlike passengers, cabin crew are often engaged in high-level activity; they board the aircraft when exposure to aircraft engine emissions may be

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The Airliner Cabin Environment and the Health of Passengers and Crew high, and they deal chronically with stressful conditions such as disrupted circadian rhythms. A compilation of cabin crew and passengers’ complaints is presented in Table B-1 (Pelletier 1998). These complaints are similar to those reported by occupants of offices associated with BRS, however, they have not received the same scrutiny, because systematic surveys of cabin crew, comparable to those in the BRS literature, are relatively rare (see Chapter 6). Lee et al. (2000) designed a questionnaire to evaluate cabin crew responses to a variety of conditions including health complaints. Health complaints included eye, nose, and throat irritation; indices of dizziness; breathing difficulties; skin dryness; gastrointestinal problems; and nausea. The three symptoms reported most often by the crew were dry, itchy, or irritated eyes; dry or stuffy nose; and skin dryness or irritation. One-third or more of the crew rated irritation and dryness as the most severe symptoms. For a larger Swedish study on air quality (Lindgren et al. 2000), 1,513 aircraft crew members (i.e., pilots and cabin crew) and 168 office workers were recruited. Aircrew had a higher incidence of complaints about poor air quality on aircraft than office workers did about building air quality. A major portion of such aircrew complaints is likely attributable to the extremely low relative humidity in the cabin (5%) during the international flights, compared with humidity levels of 20% or higher in buildings. For reference, the lower bound of the American Society of Heating, Refrigerating and Air-conditioning Engineers (ASHRAE) standard for relative humidity ranges from 20% to 30% depending on temperature (ASHRAE 1992). Lindgren et al. note that general complaints about the work environment, more common among flight crew members than office workers, may be attributable to other factors such as work stress. Passengers A survey of passengers who completed self-administered questionnaires on a variety of aircraft and flight lengths, used a 7-point scale from “poor” to “excellent” to obtain comfort ratings for a variety of characteristics including air quality (Rankin et al. 2000). Dryness and irritation, along with back or joint pain, received the lowest comfort ratings, but the mean ratings were average (4.0) or better; the variability for these ratings were not given. Although no major problems with air quality were reported by passengers, the authors noted the desirability of obtaining objective measures of air quality that can be correlated with passenger comfort ratings. Addressing this data gap is critical

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The Airliner Cabin Environment and the Health of Passengers and Crew TABLE B-1 Complaints of Flight Attendants and Passengers, 1993–1997   Flight Attendants Passengers Total Major Symptoms % No. of complaints % No. of complaints % No. of complaints Headache (severe) 15 279 12 67 15 346 Difficulty breathing (great)a 15 266 13 72 14 338 Nauseab 12 225 15 86 13 311 Dizziness 14 260 7 38 13 298 Fatigue (sudden)c 13 227 11 63 12 290 Throat problemd 7 132 5 30 7 162 Stuffiness/excessive temperaturee 5 86 12 68 6 154 Lightheadness 8 136 0 1 6 137 Chemical odor problemf 4 78 5 29 4 107 General air-quality complaint 2 45 11 61 4 106 Eye problemg 2 45 3 20 3 65 Fainted 0.3 6 5 31 2 375 Heart palpitations 1 17 1 6 1 23 Othersh 0.4 8 0 0 0.3 8   10   Total 100 1,810 100 572 0 2,382 aDifficulty breathing (great) includes lack of air or oxygen, shortness of breath, catching breath, gasping for air, chest pains, and pressure on chest. bNausea includes stomach pain, vomiting, and malaise. cFatigue (sudden) includes tiredness, weakness, faintness, and exhaustion. dThroat problem includes sore throat, nose and sinus problems, ear ringing, and congestion. eStuffiness and excessive temperature includes sweating. fChemical odor problem includes strong odor, fumes, and foul smell. gEye problem includes swelling, dryness, soreness, itchiness, and blurred vision. hOthers includes paleness. Source: Adapted from Pelletier (1998).

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The Airliner Cabin Environment and the Health of Passengers and Crew because such information would help determine the validity of the rating scale. One common complaint of crew and passengers is eye irritation, which is also a frequent complaint in BRS situations (e.g., Wargocki et al. 2000). In response to such complaints, Backman and Haghighat (2000) surveyed air quality on 15 different aircraft at different times and altitudes. The authors periodically measured CO2, temperature, and humidity. The data convinced them that poor air quality can cause contact lenses intolerance and eye irritation. The authors urged ventilation for aircraft be improved to reduce such symptoms. Comparisons of Contaminant Levels in Aircraft and Buildings Only a few studies have measured speciated organics within aircraft cabins. As indicated above, similar contaminants have been identified in both the aircraft and building environments. Table B-2 compares selected VOCs concentrations measured in aircraft cabins with concentrations measured in public, commercial, and residential buildings. The “Aircraft (1994)” column is based on measurements on 22 flights with nine different types of aircraft, and the “Aircraft (1996)” column stems from measurements on 27 flights with a single aircraft type (Boeing 777). The last four columns in the table present typical concentrations of organic compounds found in different buildings. The concentrations in aircraft do not appear to differ significantly from those found in buildings. The one exception is ethanol, which is found at significantly higher concentrations in aircraft. The ethanol concentrations probably reflect volatilization from alcoholic beverages served on the aircraft and exhalation by passengers who have consumed those beverages. However, the elevated ethanol concentrations are not expected to be a health or comfort concern as the threshold-limit value for ethanol is 1,000 ppm. Table B-3 compares the concentrations of formaldehyde, some inorganic gases, particles, bacteria, and fungi measured in aircraft cabins with concentrations measured in public, commercial, and residential buildings. The air-quality measurements are a subset of the more complete listing provided in Chapter 1, Table 1–2. The data represent four recently published studies and, therefore, are measurements made well after smoking was banned on domestic flights. The building data are measurements from public buildings and exclude situations with either smoking or cooking. The nitrogen oxide concentrations reported in the National Institution for Occupational Safety and Health aircraft study are high relative to concentrations typically measured within buildings.

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The Airliner Cabin Environment and the Health of Passengers and Crew TABLE B-2 Concentrations (mg/m3) of Selected VOCs in Aircraft Compared with Public, Commercial, and Residential Buildings VOC Aircraft (1994), Rangea Aircraft (1996), Rangea Building Mix, Weighted Averageb Office Buildings, Geo. Meanc Office Buildings, Mediand Office Buildings, Range, Mediane Ethanol 280–4,300 290–2,600 50–100 36 — — Acetone 74–150 52–140 20–50 10.2 — 7.1–220, 29 2-Propanol — 12–43 — 5.6 — — Toluene 0–29 9–19 20–50 9.8 6 1.6–360, 9 1,1,1-Trichloroethane 0–3 0–5 20–50 24.3 — 0.6–450, 3.6 meta- & para-Xylene 0–8 2–4 10–20 9.1 5 0.8–96, 5.2 Ethyl acetate 0–4 0–26 5–10 1.1 — 0.2–65 n-Decane 0–6 2–5 5–10 2.9 6 0.3–50 n-Undecane 0–20 4–20 1–5 7 9 0.6–58, 3.7 1,2,4-Trimethylbenzene 0–4 0–2 5–10 3.9 5 0.3–25 2-Butanone 3–16 4–8 1–5 — — 0.7–18 Benzene 1–6 — 5–10 3.2 — 0.6–17, 3.7 Tetrachloroethylene 0–16 5–28 5–10 2.7 4 0.3–50 ortho-Xylene 0–3 0–2 5–10 3 2 0.3–38 n-Hexane — 0–20 1–5 1.8 — 0.6–21, 2.9 d-Limonene 12–24 2–45 20–50 6.7 6 0.3–140, 7.1 aSource: Dumyahn et al. (2000). bBased on a summary of 50 studies conducted in more than 1,200 buildings between 1978 and 1990. The indoor geometric mean concentrations from multiple studies are summarized as a “weighted average” of geometric means. Source: Brown et al. (1994). cGeometric means of the most frequently identified VOCs in 12 California office buildings, selected without regard to worker complaints. Included are naturally and mechanically ventilated buildings. Source: Daisey et al. (1994). dSelected VOCs identified in the administrative facilities (11 of the 70 buildings) and their median concentrations are reported. Source: Shields et al. (1996). eRange of indoor concentrations for selected VOCs identified in the EPA BASE (Building Assessment Survey Evaluation) study. For several compounds, median concentrations are also reported. The cited database contains measurements from 56 buildings. Source: Girman et al. (1999).

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The Airliner Cabin Environment and the Health of Passengers and Crew TABLE B-3 Concentrations of Formaldehyde, Selected Inorganic Gases, Particles, Bacteria, and Fungi in Aircraft Compared with Public, Commercial and Residential Buildings Contaminant Aircraft, Rangea Aircraft, Rangeb Aircraft, Rangec Aircraft, Ranged Office Buildings, Median or Range Formaldehyde — — <1–70 ppb 0-<0.07 ppb 11.4 ppbe Nitric oxide (NO) — 0–81 ppb — (NO & NO2) 0–100 ppbf Nitrogen dioxide (NO2) 23–60 ppb 4–32 ppb — <200–3,100 ppb 30 ppbf Sulfur dioxide — 1–3 ppb — — 1 ppbg Carbon monoxide 0.8–1.3 ppm 1.9–2.4 ppm <0.1–7 ppm <0.2–9.4 ppm <1–6 ppmh Carbon dioxide 1,200–1,800 ppm 418–4,752 ppm 330–3,157 ppm 310–1,600 ppm 400–1,400 ppmi Ozone 2–10 ppb 0–90 ppb 2–122 ppb <50–1,000 ppb 0–120 ppbj Particles 3–10 mg/m3 7.6 mg/m3 25–200 mg/m3 30–380 mg/m3 25 mg/m3h Bacteria — 44–93 CFU/m3 0–1,763 CFU/m3 — <7–1,000 (20) CFU/m3e Fungi — 17–107 CFU/m3 0–450 CFU/m3 — <7–5,000 (35) CFU/m3e aSource: Spenger et al. (1997). bSource: Lee et al. (1999). cSource: Nagda et al. (2001). dSource: Waters et al. (2001). eSource: Girman et al. (1999); for bacteria and fungi median values are in parentheses; CFU, colony forming units. fSource: Wilson et al. (1993). gSource: Brauer et al. (1991). hIn the absence of indoor combustion appliances, indoor carbon monoxide concentrations will be comparable to outdoor levels. In the absence of smoking, cooking or other strong particle sources, indoor particle concentrations are comparable to or lower than outdoor concentrations. In 1999, the U.S. average concentration for particulate matter with an aerodynamic diameter of 10 μm was 25 mg/m3. Source: Adapted from EPA (2000). iSource: Nabinger et al. (1994). jSource: Weschler (2000).

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The Airliner Cabin Environment and the Health of Passengers and Crew Other aircraft studies have not reported similarly high nitrogen oxide concentrations. The high end of CO2 measurements in aircraft cabins appears to be above that typically measured within buildings. In aircraft, O3 concentrations are also higher than those typically found in buildings. The results of Nagda et al. (2001) and Waters et al. (2001) indicate that the particle concentrations in aircraft may occasionally be higher than those encountered in buildings in the absence of smoking and cooking. This finding may reflect particles generated during inflight meal preparation or those brought into the cabin when the aircraft is on the ground, especially on the runway waiting for takeoff. CONCLUSIONS Although this appendix outlines similarities between building and aircraft environments, a comparison is limited by the lack of data on exposures in the aircraft environment. More data on exposures to contaminants on aircraft are needed. Unlike the volume of BRS research in buildings, research on the association of cabin air quality with health complaints of passengers and crew is sparse. The bulk of information about symptoms or complaints (e.g., irritation) comes from reports filed by air crews. These reports are not solicited by a regulatory or health agency or gathered in a systematic manner, and are primarily a response to air-quality incidents. As emphasized in Chapter 6, systematic information about symptoms must be acquired using appropriate methods and tools for measuring subjective health and comfort variables such as irritation and fatigue. REFERENCES ASHRAE (American Society of Heating Refrigerating and Air-Conditioning Engineers). 1992. Thermal Environmental Conditions for Human Occupancy. ANSI/ASHRAE 55–1992. American Society of Heating, Refrigerating, and Air-Conditioning Engineers, Atlanta, GA. Apte, M.G., W.J.Fisk, and J.M.Daisey. 2000. Associations between indoor CO2 concentrations and sick building syndrome symptoms in U.S. office buildings: an analysis of the 1994–1996 BASE study data. Indoor Air 10(4):246–257. Backman H., and F.Haghighat. 2000. Air quality and ocular discomfort aboard commercial aircraft. Optometry 71(10):653–656. Brauer, M., P.Koutrakis, G.J.Keeler, and J.D.Spengler. 1991. Indoor and outdoor

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The Airliner Cabin Environment and the Health of Passengers and Crew Weschler, C.J. 2000. Ozone in indoor environments: concentration and chemistry. Indoor Air 10(4):269–288. Wilson, A.L., S.D.Colome, and Y.Tian. 1993. California Residential Indoor Air Study. Vol. 1. Methodology and Descriptive Statistics. Integrated Environmental Service, Irvine, CA and Gas Research Institute, Chicago, IL. May 93. 125pp. NTIS PB94– 1660551.