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Health-Protective Features and Practices in Buildings

James E. Woods

INTRODUCTION AND PROBLEM STATEMENT

My objectives are to identify (a) the best-available research and empirical evidence that supports facilities-related policies and practices that could result in better indoor environmental quality (IEQ) if implemented and (b) barriers to the implementation of these policies and practices. To achieve these objectives, several topics and issues are addressed. These include the purposes of buildings, current building stock, current drivers for building performance, and stakeholders. A second topic is the current state of knowledge about the performance of buildings and their systems as they relate to environmental controls and health-protective practices. A final topic is barriers to improving performance of new and existing facilities.

Primary and Secondary Purposes of Buildings

Historically, buildings have been designed, constructed, and operated for two fundamental purposes: (1) to provide for the health, safety, and security of their inhabitants and (2) to facilitate the well-being and productivity of occupants, building owners, and managers. These purposes follow two basic principles: the Maslow Hierarchy of Needs[1]1 and the definition of “health” in the Constitution of the World Health Organization [2].2

The five functional categories of buildings addressed are: residential, educational, health care, office and mercantile, public assembly and worship. The industrial building category is not discussed because exposures of workers to indoor environmental stressors3 in industrial facilities are typically considered to be significantly different than exposures of occupants to indoor environmental stressors in nonindustrial facilities.

1  

The five levels in Maslow’s Hierarchy of Needs are: (1) Physiological, (2) Safety and Security, (3) Belonging, (4) Esteem, and (5) Self-actualization.

2  

The World Health Organization definition: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.”

3  

In this paper, IEQ is defined as the nature of physical and chemical characteristics (i.e., stressors) within the building that stimulate physiological receptors and result in human (i.e., physiological, psychological, pathological) responses. And exposure (E) is defined as: E = IIC dT dS, where C is type and concentration (i.e., intensity) of the stressor(s), S is the space in which exposure occurs, and T is the time in each space during which the stressor(s) stimulate the receptors.



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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings 3 Health-Protective Features and Practices in Buildings James E. Woods INTRODUCTION AND PROBLEM STATEMENT My objectives are to identify (a) the best-available research and empirical evidence that supports facilities-related policies and practices that could result in better indoor environmental quality (IEQ) if implemented and (b) barriers to the implementation of these policies and practices. To achieve these objectives, several topics and issues are addressed. These include the purposes of buildings, current building stock, current drivers for building performance, and stakeholders. A second topic is the current state of knowledge about the performance of buildings and their systems as they relate to environmental controls and health-protective practices. A final topic is barriers to improving performance of new and existing facilities. Primary and Secondary Purposes of Buildings Historically, buildings have been designed, constructed, and operated for two fundamental purposes: (1) to provide for the health, safety, and security of their inhabitants and (2) to facilitate the well-being and productivity of occupants, building owners, and managers. These purposes follow two basic principles: the Maslow Hierarchy of Needs[1]1 and the definition of “health” in the Constitution of the World Health Organization [2].2 The five functional categories of buildings addressed are: residential, educational, health care, office and mercantile, public assembly and worship. The industrial building category is not discussed because exposures of workers to indoor environmental stressors3 in industrial facilities are typically considered to be significantly different than exposures of occupants to indoor environmental stressors in nonindustrial facilities. 1   The five levels in Maslow’s Hierarchy of Needs are: (1) Physiological, (2) Safety and Security, (3) Belonging, (4) Esteem, and (5) Self-actualization. 2   The World Health Organization definition: “Health is a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity.” 3   In this paper, IEQ is defined as the nature of physical and chemical characteristics (i.e., stressors) within the building that stimulate physiological receptors and result in human (i.e., physiological, psychological, pathological) responses. And exposure (E) is defined as: E = IIC dT dS, where C is type and concentration (i.e., intensity) of the stressor(s), S is the space in which exposure occurs, and T is the time in each space during which the stressor(s) stimulate the receptors.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Building Stock Approximately 4.7 million nonresidential, nonagricultural, nonindustrial buildings and 107 million residential buildings exist in the United States [21, 22].4 The annual rates of growth and replacement of this building stock have been approximately 2 percent for residential buildings and 4 percent for nonresidential, nonindustrial buildings for the past 20 years [23]. Thus, approximately 2 million residences and 200,000 “commercial” buildings are constructed annually in this country. A summary of characteristics for four types of “commercial” and four types of residential buildings is shown in Table 3.1. The four functional categories of “commercial” buildings were selected because they represent a significant percentage of the existing building stock (i.e., note that with the warehouse and “vacant” categories from the total population, these four categories represent more than 50 percent of the total). Several important demographic factors may be observed from the table: The percentages of government-owned office buildings and health care facilities are relatively low, while the percentage of government-owned (i.e., local, state, and federal) educational facilities is relatively high, and the percentage of owner-occupied facilities appears to be approximately inversely related to the percentage of government-owned facilities. The distribution of the building stock (i.e., both commercial and residential) appears to follow a geographic pattern in which the largest numbers of buildings in each category are located in the southern (i.e., Southeast and Southwest) part of the United States, followed by the Midwest, West, and Northeast. The median sizes of the commercial buildings are significantly smaller than are typically perceived. Half of the commercial buildings are in the smallest category (1,001 to 5,000 ft2), and three-quarters are in the two smallest sizes (1,001 to 10,000 ft2). Approximately 5 percent were larger than 50,000 ft2, and less that 2 percent were larger than 100,000 ft2. However, the population distribution appears to be inversely proportional to these numbers: nearly half of all workers are in 5 percent of the buildings (i.e., larger than 50,000 ft2), while only about one-quarter of all workers are in 75 percent of the buildings (i.e., 10,000 ft2 or less). The median age of buildings in all categories is more than 20 years, and the residential stock appears to be older than the commercial stock. The median ages exceed the life expectancy for much of the equipment in these buildings. Concept of Continuous Degradation The concept of continuous degradation of the building stock was proposed in 1988 [24] and continues to serve as a model with which the chronology of building performance can be characterized. Briefly, this concept states that buildings are not conceived to cause harm, but as they progress from the planning and design stages through construction to operations, degradation will occur through compromises unless it is detected and intervention is implemented. Based on studies conducted in the 1980s, this concept proposed that 20 to 30 percent of the building stock in North America and Western Europe was sufficiently dysfunctional to manifest in occupants symptoms of disease and that another 10 to 20 percent existed in a classification called “undetected problems,” leaving a residual population of 50 to 70 percent as “potentially healthy” buildings. Since then several studies have been reported that support this concept, three of which are mentioned here: During the 1990s, the U.S. General Accounting Office (GAO) published a series of reports on the conditions of American schools [25]. The GAO reported that about 58 percent of school facilities in the United States 4   Note the Energy Information Agency (EIA) [17] defines the nonindustrial, nonagricultural, nonresidential category of buildings as “commercial” buildings. This category contains several functional categories, including office, mercantile, warehouse and storage, retail service, food service, education, religious worship, public assembly, “vacant,” food sales, lodging, malls, health care, and public order and safety.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings TABLE 3.1 Summary Characteristics of Four “Commercial” Building Types and Four Residential Building Types from EIA [21, 22] Building Category Description % Total Buildingsa % Government Owned % Owner Occupied % Census Distribution Median Size (ft2) Median Age (years) NE MW S W Office General office space, professional office, administrative office 15 (26) 7 69 14 23 42 20 4,500 24.5 Education Preschool, K-12, classroom buildings in universities and colleges 7 (11) 59 33 9 13 37 41 8,000 35.5 Health care Diagnostic and treatment facilities: 3 (4) 6 60 11 26 46 16       • Inpatient               65,000 29.5   • Outpatient               4,500 9.5 Public Assembly Social and recreational activities 6 (11) 21 67 14 29 41 16 6,500 32.5 Residential     NAb   19 23 36 22 NAb     • Single Family (SF) 59   88           40     Detached Garage                 35   • SF Att Gar. 10   71           50   • Multi-Family (MF) 9   22           40     (2-4 units)                 30   • MF (≥5) 16   10               • Mobile Home 6   84             a Numbers shown in parentheses represent percentages of total buildings when “warehouses” and “vacant” categories have been removed from the total population (i.e., revised total population is 3.8 million rather than 4.7 million buildings). b Data on government-owned residential facilities were not provided in [22].

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings had at least one unsatisfactory environmental condition, and about 13 percent had five or more. Those most frequently reported were acoustics for noise control (28 percent), ventilation (27 percent), physical security (24percent), heating (19 percent), indoor air quality (19 percent), and lighting (16 percent). The GAO estimated that schools nationwide needed to spend about $112 billion to repair or upgrade them to good overall condition, an average of $1.7 million per school. In 2000 the Institute of Medicine [26] reported on its findings regarding the relationship of asthma and indoor air quality. One of its conclusions was that “damp conditions [in residential and commercial buildings] are associated with the presence of symptoms considered to reflect asthma; symptom prevalence among asthmatics is also related to dampness indicators.” The underlying causes of the moisture problems were reported to include “inadequate financial resources to repair leaks, that the relevant features of building design, operation and maintenance may be determined substantially by speculative builders or other decision-makers who are substantially unaffected by future moisture problems. Similarly, landlords who do not reside in the affected building may not be motivated to repair water leaks rapidly.” In January 2003 the GAO released a report declaring that federal real property was a governmentwide “high-risk” area [3]. The GAO reported that the Department of Defense found that as many as two-thirds of its 621,850 installations and facilities “are not adequate to meet the war-fighting and operational concepts of the 21st century.” The GAO also reported that, when compared to other schools nationally, “schools operated by the Bureau of Indian Affairs (BIA) were generally in worse condition, had more environmental problems, lacked certain key facilities, and were less able to support advancing technologies.” BIA reported in 2001 “a significant backlog of deferred maintenance and that the conditions in the educational facilities were negatively affecting the ability of the children to perform.” The General Services Administration (GSA) reported to the GAO that “half of its 1700 buildings needed repairs at about $5.7 billion.” In 2001, the GAO observed poor health and safety conditions in GSA buildings due to “dysfunctional air ventilation systems, inadequate fire safety systems, and unsafe water supply systems.” The population at risk in these degrading buildings is large. For the commercial buildings shown in Table 3.1, the ratios of total occupants to employees range from approximately 1:1 for offices, to 4:1 in educational facilities, to 7:1 for health care facilities, to more than 50:1 in some public assembly buildings. Based on the findings that the population spends approximately 90 percent of its time indoors, the concept of continuous degradation was used to project initial estimates of the probabilities of exposures in “healthy” and “sick” residences and commercial buildings [27]. These estimates ranged from 9 to 25 percent probabilities (i.e., 15 million to 60 million U.S. occupants) who may be exposed in both “sick” residences and “sick” commercial buildings, to 25 to 50 percent (i.e., 40 million to 120 million occupants) who may be exposed in both “healthy” residences and “healthy” commercial buildings, to 30 to 70 percent (i.e., 40 million to 170 million occupants) who may be exposed in either “sick” residences or commercial buildings. These numbers are substantially higher than the 82 million to 89 million employees estimated by EIA [21] and the National Institute for Occupational Safety and Health [28] to be exposed in all commercial building conditions for two reasons: (1) they limited their consideration to workers only and did not consider the total occupant (i.e., visitor, patient, student, audience) to employee ratios, and (2) they did not consider the probability of adverse exposures in both residential and other indoor facilities. Current Drivers for Building Performance and Stakeholders The performances of buildings have been driven by myriad influences and agendas advocated by stakeholders from the public and private sectors. Some of the current drivers have been grouped into three interrelated categories in Figure 3.1. Within each category is a set of drivers, any one of which may dominate decision making during any period in a building’s life cycle. Historically, the drivers and their interactions have been dynamic, with changing factors and priorities.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings FIGURE 3.1 Three sets of current drivers: environment, energy, and productivity. Not only are the drivers diverse and potentially conflicting, the stakeholders who advocate them often have competing interests. The large number of stakeholders5 and their diverse interests complicate efforts to achieve a consensus approach in addressing potential means or methods to improve indoor environmental quality. Thus, a fundamental issue is: how should the changing drivers and priorities of the stakeholders be accommodated while advancing the health-protective features and practices in building design, construction, and operations? Comparing the current drivers in Figure 3.1 with the range of stakeholders and their interests provides a perspective of the current situation regarding the need to assure or improve health protection in the various functional categories of buildings. Several of the drivers can be synergistic with health-protective features and practices, but they can also be antagonistic. For example, to achieve certain energy, environmental, or economic objectives, some stakeholders may tend to suppress consideration of the health consequences of their decisions (e.g., maximize the use of “green” materials, minimize energy consumption, or minimize costs through “value engineering”). This comparison also reveals that accountability for health protection in nonindustrial buildings is not well defined. One reason may be that designers, consultants, contractors, and suppliers do not have the education or training to assume this accountability. Less than 2 percent of architectural and engineering curricula in the early 1990s required any formal health science courses [16]. Informal surveys conducted at seminars by the author support this finding throughout the 1990s. Moreover, similar findings are reported in curricula at schools of medicine and public health [72]. Yet licensed architects and engineers are expected, within their fields of practice, to protect the general health and safety of the general public, and licensed health care professionals are expected to diagnose and treat patients who have been affected by exposures in buildings. 5   A partial list of stakeholders includes owners of private or public property, agents of owners, tenants, designers and their consultants, contractors and their subcontractors, suppliers of products or services, occupants, policy makers, politicians, financiers, insurance carriers, health care practitioners, litigators and their consultants, researchers, and educators.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Economics The National Occupational Research Agenda (NORA) report [28] presents one of the latest in a series of prospective and speculative studies on projected costs and benefits expected to be realized by improvements in control of the indoor environment [3, 25, 27, 60, 69]. Although these studies project health benefits that far exceed the projected costs of achieving them, none of the studies has been verified with actual costs and benefits, either on a micro- or macroeconomic scale. Microeconomics Each of the 107 million existing residences and 4.7 million existing commercial buildings in the United States has a set of microeconomic issues that are important to the concerned stakeholders. Moreover, each of the 2 million residences and 200,000 commercial buildings to be constructed in the next 12 months has another set of microeconomic issues that are important to the same or to different stakeholders. And as shown in Figure 3.1, health benefits and costs are only one of many drivers currently used to make economic decisions regarding the design, construction, or operations and maintenance of buildings. Short of litigation, no one is currently accountable for the impact that the performance of a building has on the health of the occupants, either in the private or public sector. Therefore, within the existing building stock, maintenance is being deferred to an alarming extent [3, 25]. And for new buildings the financial incentives are for low first costs or for “green” or “energy-efficient” buildings [12, 47]. With regard to preparing for extraordinary incidents, and with few exceptions, the current position in the private and public sectors is to wait until regulations are promulgated or federal money is allocated before additional costs are invested to improve preparedness or responsiveness, unless the interventions can be justified by projections of improved health, occupant performance, or productivity. Macroeconomics With regard to policy, the GAO has been sounding the alarm for over a decade that major health effects are likely to occur in schools and federal buildings [3, 25]. In 2002 the President signed the Elementary and Secondary Education Reauthorization Act of 2002 (popularly referred to as the “No Child Left Behind Act”). Section 5414 of the act mandates the completion of a study by the U.S. Department of Education and submission of a report to Congress within 18 months of enactment characterizing the problems in unhealthy schools at the K-12 levels, together with recommendations to Congress for remedial actions. Unfortunately, this was an unfunded mandate, and little has been done to move this work forward. And it is too early to predict what the disposition of the GAO report identifying federal real property as a governmentwide high-risk area will be. Available Data An extensive international body of scientific, technical, and marketing literature now exists that supports the interests and drivers of the various stakeholders. As reported in 1998 [15] and presumed to still be valid today, a small percentage of this literature is the result of careful scientific research, in which effective experimental designs have been used to obtain original data in laboratory or field studies. A greater percentage of this literature consists of reanalyses of the results from the original studies, speculative studies based on those analyses, and anecdotal results derived from investigations of complaints. And an even greater percentage of the literature consists of marketing reports based on surveys and testimonials. Moreover, the terminology found in the literature is frequently confounded or not clearly defined. For example, “measures” of human response (e.g., discomfort complaints, symptoms), occupant performance, and productivity are often used interchangeably [15], and the concept of life-cycle costing has become suspect because of the uncertainties in the assumptions needed for the calculations.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Additional credibility challenges have been experienced since the terrorists attacks on the World Trade Center and the Pentagon on September 11, 2001, and the subsequent anthrax incidents in October and November 2001. As a result of these attacks, information was immediately promulgated in the news media that outdoor air intakes should be closed, air-conditioning systems should be shut off, and high-efficiency filters should be installed. And during an elevation in the alert status promulgated by the U.S. Department of Homeland Security in February 2003, the general population was advised that health protection should include the use of duct tape and plastic over doors and windows. Building Codes and Standards In practice, this literature has formed the foundation for building codes, governmental regulations, standards, and guidelines that express the “standard of care” expected by a community for the design, construction, and operation of buildings. However, this “standard of care” does not currently include health protection, although the general public expects this protection.6 Local building codes are often derived from model codes promulgated by organizations such as the International Code Council [4] and the National Fire Protection Association [5]. These model codes, in turn, are developed from consensus processes involving review and interpretation of available standards and guidelines, literature, and professional experience. Because a credible body of data exists pertaining to catastrophic failures of building structures and systems, and the resultant casualities, building codes primarily address structural and “life-safety” issues. However, with the exception of plumbing and water quality criteria, building codes seldom address “health” issues. Moreover, building codes primarily address design and construction issues and are enforced by “permitting” and “inspection” processes. With the exception of fire-safety codes, which are enforced by fire marshals within a community, building codes seldom address building operations. Fundamental reasons why health protection is not more predominantly addressed in building codes may be that pathogenic effects usually occur over extended periods of exposure (i.e., chronic vs. acute effects); individual susceptibilities and other exposures confound the linking of documented adverse health effects to specific building features and practices; and other competing interests (e.g., professional liability) create barriers to establishing a health basis for building codes. Standards and guidelines are most notably promulgated by nationally recognized technical and trade organizations, such as the American National Standards Institute [6], the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) [7], ASTM International (formerly the American Society for Testing and Materials) [8], the Air-Conditioning and Refrigeration Institute [9], the North American Insulation Manufacturers Association [10], the Sheet Metal and Air-Conditioning Contractors National Association [11], and the U.S. Green Building Council [12]. Although they do not carry the weight of enforcement that is associated with building codes and government regulations, they serve as a foundation for building codes and regulations, and compliance with them may also be included as a contractual requirement on specific projects. These standards and guidelines, which are generally developed from consensus processes involving professional experience together with review and interpretation of available literature, provide guidance pertaining to several of the drivers shown in Figure 3.1. Like building codes, guidance on control for health effects is rarely provided in building standards and guidelines. Rather, consideration of health effects is almost always explicitly excluded, even those that are most germane to IEQ. Moreover, the large number of standards and guidelines promulgated by these organizations with regard to environmental quality, energy, and economics contain actual or potential conflicts in various documents, within and between organizations. 6   Architects and engineers are licensed in their fields of practice by the states to “protect the health and safety of the general public.”

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings CURRENT STATE OF KNOWLEDGE ABOUT BUILDING SYSTEMS AND ENVIRONMENTAL CONTROLS Criteria and Measurements for Environmental Control To achieve the primary purposes of buildings, methods of environmental control are needed. The objectives of environmental control may be expressed as (1) prevention of adverse health and safety effects and (2) provision for desired conditions of human response, occupant performance, and productivity. These objectives can be achieved by simultaneously controlling within “acceptable ranges” exposures of physiological receptors that sense four primary environmental stressors: thermal, contaminant, lighting, and sound. A rational model that links measures of human responses and exposures with system and economic performance parameters was introduced in 1993 [29] and extended in 1998 [30] to differentiate between measures of human response, occupant performance, and productivity. This extended model, shown in Figure 3.2, is used here as a focus for discussion of current knowledge regarding criteria and measurements of exposure, human response, occupant performance, productivity, and safety and security. Exposures Four sets of exposures are typically considered within the physical factors for indoor environmental control purposes: thermal, contaminant, lighting, and acoustics. Each of these sets is related to physiological receptors, and each is intended to be passively or actively controlled to within specified ranges by systems (e.g., HVAC, natural ventilation and lighting, “artificial” lighting, and architectural and electromechanical acoustics). Measurable and controllable variables and recommended ranges of their values have been generally adopted for the FIGURE 3.2 An extended rational model for environmental control [30].

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings thermal (i.e., temperature, humidity, air speed), lighting (i.e., luminance, frequency), and acoustic (i.e., sound pressure, frequency) parameters [31-33]. All of these variables are associated with energy stressors7 and feedback control of physiological and physical systems. A similar set of measurable and controllable variables for the constellation of contaminants known to be present in nonindustrial environments has yet to be established or associated with mass stressors,8 although some attempts are being made through the introduction of terms such as decipol units [34], total volatile organic compounds (TVOCs) [35], and metabolic volatile organic compounds [36]. Because of a lack of sufficient knowledge to characterize indoor air quality in nonindustrial environments in terms of measurable and controllable variables, indirect or open-loop control is generally relied on today. This control is usually in the form of supplying specified rates of outdoor air for ventilation [13] and monitoring for a variety of concentrations to which occupants may be exposed,9 including particulate matter (i.e., PM10 or PM2.5 [37], pet and dust allergens [38], carbon dioxide, organic and inorganic chemicals [39], humidity, and microbials [40]. Recent concerns regarding measurable and controllable mass stressors associated with intentional releases of chemical and biological agents have intensified the need for rapid means of detection and control, as the deleterious or fatal concentrations of these agents are substantially less than those typically characterized as indoor air contaminants [17, 19]. Currently physical sensors are not commercially available or sufficiently reliable and responsive for this use. Therefore, current recommendations are to depend on open-loop methods of preparedness and control [18, 20]. Studies have also been reported that indicate significant interactions of environmental stressors. Rohles et al. [41, 42] reported that changes in lighting frequencies (i.e., warm-cool colors) and acoustic frequencies affect thermal perceptions. Jannsen et al. [43] reported that changes in carbon dioxide concentrations affect thermal perceptions. Cometto-Muniz [44] and Wargocki [45] reported that changes in temperature and humidity conditions affected odor perception. More recently, Woods et al. [46] showed evidence of two- and three-way interactions between illumination, sound pressure, carbon dioxide, and PM10 levels in classrooms. Thus, total exposure to energy and mass stressors (see footnote 2) is likely to affect both physiological responses and physical system performance. Human Responses Three sets of human responses parameters are typically considered: perceptive, affective, and objective (Figure 3.2). The perceptive and affective responses may be with regard to the environment—for example, the room is warm (environmental-perceptive) or the room is “acceptable” (environmental-affective)—or with regard to a personal state—for example, “I am warm,” “I have a headache” (personal-perceptive), “I am uncomfortable,” “I am sick” (personal-affective). The objective responses, which are also related to the personal state (personal-objective), are those that are assessed using clinical tests (e.g., clinical signs of illness or disease). With the possible exception of the personal-objective responses, measures for human responses are obtained by surveys, questionnaires, and interviews. However, as indicated in many of the forms available in the literature, the inquiries in these instruments often confound the responses. Moreover, building codes and standards typically address only the environmental-affective responses (e.g., 80 percent “acceptability,” 80 percent “visual comfort probability,” 20 percent “dissatisfaction”) [13, 31, 47], whereas complaint investigations focus on personal-perceptual and personal-affective responses. Human responses are influenced not only by the physical factors (i.e., exposures) but also by other sets of human factors (i.e., personal factors, social factors). Therefore, without information regarding personal and social 7   Energy stressors of the physiological receptors include convective (sensible and latent) heat exchange and radiation exchange in the infrared (i.e., thermal), visible, and audible spectra. 8   Mass stressors of the physiological receptors include particles, gases, and vapors that are characterized by size (e.g., molecular weight, Angstrom, micrometer) and concentration (e.g., number or mass per unit volume or surface area). 9   References 37-40 describe some new methods of measurement, as reported at Indoor Air 2002.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings factors, reports that claim to show relationships between exposures and human responses may be confounded. An example of this confounding is the issue faced by the Centers for Disease Control and Prevention’s investigation of incidents regarding the attribution of infant deaths associated with exposure to Stachybotrys chartarum [48]. Nevertheless, significant health effects have been causally linked to indoor exposures, including development of asthma in susceptible children from exposure to dust mite allergen and exacerbation of asthma in sensitive individuals from exposure to cat, cockroach, and house dust mite allergens and to environmental tobacco smoke [26, pp. 6-10]; tuberculosis [49]; legionellosis [14, 50]; and aspergillosis and other “hospital acquired infections” [51]. Reports at a recent international conference reaffirm previous studies and indicate that symptom prevalence associated with sick building syndrome is linked to thermal, chemical, and microbial exposures [52-54], and a strong psychological component has also been recently reported [55]. Occupant Performance Occupant performance is a different outcome measure than either human response or productivity. Occupant performance should be expressed in terms of measurable and controllable parameters that relate to the functions provided in the indoor space [30]. Traditionally, occupant performance is measured in terms of quality (e.g., errors/unit time), quantity (e.g., time required to complete task), or quality and quantity (e.g., learning outcome assessments, typing scores diminished by errors). Nontraditional measures include absences from work and “self-reported productivity” [15]. As indicated in the literature and shown in Figure 3.2, occupant performance is influenced by physical factors (i.e., exposures) and motivating factors such as salary, patriotism, and loyalty. The quantitative influence of these two factors on occupant performance is not well understood or documented in the literature. However, evidence demonstrates that the influence of the motivating factors can overwhelm the influence of the physical factors on occupant performance (e.g., trauma centers, command centers). Confounding or not controlling for the effects of motivating factors and other human factors may indicate why the reported effects on occupant performance continue to be so diverse in field studies [56-60]. As demonstrated recently, fear and insecurity in occupied spaces are demotivating factors and are likely to have significant effects on occupant performance if not controlled. Productivity Productivity is another outcome measure that has been confounded in the literature. As objectively defined in the literature (and shown in Figure 3.2), productivity is an economic outcome measure of the value in an interventional change in occupant performance compared to the cost of achieving that change [30]. Comparable definitions are used in two recently published tools for calculating productivity [60, 61]. The weakness in both of these tools, however, is the uncertainty of the input data. As databases become more robust, the credibility of the calculated outcomes should increase. An example of how productivity analysis can be used to inform policy was presented at Indoor Air 2002. Cunningham et al. [62] explored how managed care organizations and other health insurers can estimate the potential savings they could experience by combining medication management with environmental trigger avoidance in an asthma management program. Safety and Security Since the terrorist attacks of September 11, 2001, and the subsequent anthrax attacks that occurred in October and November of that year, three basic guidance documents have specifically addressed methods for protecting occupant health and safety from future attacks [18, 20, 63]. Each of these documents addresses the issue of assuring the preparedness of a building’s health and safety, during normal conditions, and for responsiveness during extraordinary incidents. The ASHRAE guidance extends extraordinary incidents to mean naturally occurring, accidental, or intentional. Although these documents present recommended actions, they do not provide specific criteria or recommended measures to assure compliance. However, the ASHRAE document introduces the concept of “acceptable

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings vulnerability” and suggests a risk management approach to determining those criteria and methods of compliance. Of note, each of the factors and response functions (Figure 3.2) pertains to these safety and security issues. Moreover, feedback from government agency and private-sector owners, and other stakeholders, reveals that cost-effective solutions are needed that can be justified based on improved occupant performance and productivity during normal conditions as well as preparing for health and safety responses during extraordinary incidents. Building Features and Health Protection The NORA report [28] used the phrase “health-protective features” to describe components and systems that potentially affect IEQ and occupant health. These features included the “design and materials of the building (e.g., the outside envelope, air handler, ventilation distribution system, indoor surfaces) and the contents (e.g., furnishings, office equipment).” For consistency with this concept of health-protective features and to address the two primary objectives of environmental control expressed above, the following systems are discussed as they relate to the performance of the building system as a whole. This discussion includes the considerations from the NORA report but is not limited by it. Rather, this discussion of health-protective features focuses on addressing the current drivers shown in Figure 3.1 and complying with the performance criteria described above. Structure and Envelope System The purpose of the structure and envelope system is to provide safety and protection for its occupants at all times (i.e., during normal and extraordinary loads), cost effectively and energy efficiently. The structural components of the envelope system bear the weight (i.e., static or “dead” loads) of the building materials and the contents within the building and the dynamic (i.e., “live”) loads imposed on the building (e.g., occupant, seismic, rain, snow, and wind loads). The nonstructural components of the envelope system provide for the desirable functions (e.g., entrance and egress through doorways and other passageways, visual communication and natural ventilation through windows, and aesthetic value) while providing protection for health, safety, and property inside the building. This protection is from a constellation of unwanted penetrations and intrusions (i.e., thermal, moisture, and contaminant loads; air infiltration; liquid water penetration; noise; glare, fire, and smoke; and physical security). Based on the ASHRAE report [20], the loads imposed on the structural and envelope system may be classified as normal and extraordinary loads: Normal loads are determined from “design” (i.e., probabilistic) conditions that are expected to occur on a regular basis during the lifetime of the building. The primary use of the normal load information is to select the capacities and control strategies of the structural, mechanical, and electrical systems needed to provide for health, safety, comfort, occupant performance, and productivity within the building during its lifetime. Extraordinary loads are determined from risk assessments of naturally occurring, accidental, or intentional incidents that may occur at some time during the lifetime of the building [20, 63]. The primary use of the extraordinary load information is to assure that the selected system capacities are sufficient and to modify the control strategies as necessary to protect occupant health and safety during extraordinary incidents (e.g., safe egress, isolation of affected area). Structural and envelope systems seldom consist of monolithic components. Rather, they are comprised of many multifunctional materials and connections and may or may not contain wall, roof, or floor “cavities.” The properties of these materials and connections should include the following health-protective features: thermal resistance and capacitance; resistance to air infiltration; resistance to water vapor, particulate, and gaseous contaminant transmission; fire resistance; resistance to mold growth; acoustic and light absorption and reflectance; low chemical emission; durability; toughness; maintainability; and aesthetic quality. The values for these properties are available in design handbooks and in manufacturers’ literature. Selection of the appropriate materials and connections, which is usually accomplished by agreement of the several stakeholders (e.g., owner, architect, contractor, supplier, building code administrator, tenant, occupant), has significant economic consequences [64, 65]. Moreover, the selection of these materials and connections significantly affects the normal and extraordinary loads that must be controlled by other systems.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Heating, Ventilating, and Air-Conditioning (HVAC) Systems The purpose of HVAC systems is to provide for the health, comfort, and safety of the occupants at all times (i.e., during normal and extraordinary loads), cost effectively and energy efficiently. With the exception of radiant heating and cooling processes, air movement is the fundamental method used by HVAC systems to control the temperature, humidity, contaminant concentrations, and pressurization in occupied spaces. The capacities and complexities of HVAC systems vary widely from small self-contained room air-conditioning units to sophisticated systems used in therapy and in hostile environments (e.g., surgical suites, chemotherapy treatment facilities, burn-patient treatment facilities, biocontainment research laboratories, submarines, and satellites). Yet the function of all HVAC systems is common: to provide, in response to envelope and internally generated thermal and contaminant loads, the required heating and humidification, ventilation and air cleaning, cooling and dehumidification, and air distribution and pressurization to maintain thermal and indoor air quality exposures within “acceptable ranges.” Controllability may be the most important health-protective feature of HVAC systems. Design or peak loads are imposed within the basic zones of control for relatively short periods of time during normal conditions. For example, design summer and winter conditions for thermal loads are typically assumed to occur for less than 5 percent of the year [67], design dew-point conditions may occur for less than 2 percent of the year [67], and peak periods of pollen and other allergen releases may occur for only short periods of time (usually during moderating weather conditions). Therefore, for nearly 90 percent of the time during normal conditions, the HVAC system capacities do not match the partial loads, and controls are used to reduce the system outputs by cycling components on and off or by modulating motors on fans, dampers, and valves. Without adequate control to ensure that the exposure criteria are maintained during these part-load conditions, the risk of adverse health effects increases. Preparedness of HVAC systems to respond to extraordinary incidents is also a vital control function. In cases where accidental incidents (e.g., fires, floods, chemical spills) or intentional incidents (i.e., external or internal releases of chemical, biological, or radiological agents) occur, life-safety control strategies for the HVAC systems provide for isolation of the release zone, compartmentalization, emergency use of redundant and supplemental systems, and safe egress [5, 20, 63]. For fire and smoke control, the life-safety codes require that certain HVAC systems be identified for such use and provided with emergency, stand-by power. Lighting and Acoustic Systems The purpose of lighting and acoustic systems is to provide for the comfort and safety of the occupants at all times (i.e., during normal and extraordinary loads), cost effectively and energy efficiently. In several respects, the methods of control for lighting and acoustics in occupied spaces are similar: (1) both systems depend on reflective and absorptive characteristics of the surfaces within the occupied space; (2) both require control of intensities over frequency spectra; (3) both have natural and amplified mechanisms of control; (4) both have characteristics that are associated with symptoms of sick building syndrome (e.g., headaches; fatigue; nausea; dizziness from excessive glare, sound, and vibration); (5) both contribute significantly to the well-being of society (e.g., art galleries, museums, concert auditoriums, theaters) as well as to functional applications (e.g., homes, schools, offices, public assembly, hospitals); and (6) both have strong interactions with envelope and HVAC systems (e.g., lighting loads, noise reduction and transmission). During extraordinary conditions, lighting and acoustic systems also serve vital functions, as they provide guidance and enable egress for occupants and entry for first responders. For fire and smoke control, life-safety codes now require certain lighting and acoustic systems to be designated for this purpose and to be provided with emergency standby power. Enclosure Systems and Furnishings (Open- and Closed-Occupancy Areas) The purpose of enclosure systems and furnishings is to provide for the comfort and performance of the occupants during normal conditions, safely and cost effectively. Enclosure systems include fixed and movable

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings walls and partitions, ceilings, and flooring that define spaces for occupancy in each of the building categories shown in Table 3.1. The sizes of enclosure systems vary widely: from open-office modules of approximately 36 ft2 (telemarketing and some administrative work), to 150 ft2 for management offices, to 1,000 ft2 for classrooms, to large public assembly areas. Furnishings for these occupied spaces include built-in, free-standing, and wall-hung desks, bookcases, and cabinets; chairs, computers, printers, and other office equipment; and carpeting, wall coverings, and personal items. Enclosure systems and furnishings contribute to thermal, lighting, acoustic, and contaminant loads that must be dissipated by the HVAC systems [66]. As a means to enhance worker performance, flexibility of the enclosure systems has been emphasized [67], including the ability to provide electrical power, HVAC, and communications wiring to these enclosure systems. As a result, most commercial buildings have been provided with ceiling plenums that contain supply air (and sometimes return air) ducts, power and communications wiring, and piping for plumbing and fire protection (sprinkler) systems. More recently, a trend toward the use of raised floors to provide easier access to electrical power and communications wiring has been noted. Moreover, some of these raised-floor systems are now providing underfloor air distribution (UFAD) [67, 68]. The health effects from exposure in these enclosure systems, especially the UFAD systems, are not yet known. Although a preliminary set of field studies [68] reveal that the frequencies of occupant discomfort complaints and symptoms of sick building syndrome are not dissimilar to those in other commercial buildings, concerns from consulting engineers and contractors have been expressed that the pathways from contaminated surfaces in unducted floor plenums to the breathing levels of occupants is much shorter than in conventional systems. Other concerns expressed about UFAD systems by consulting engineers and contractors are that isolation and compartmentalization are difficult for fire protection and, more recently, for protection against accidental or intentional chemical or biological releases. Building Automation Control Systems The purpose of building automation control systems (BACS) is to provide a centralized location where the performance of buildings can be evaluated. Conventional feedback control systems seldom presented reliable information at a centralized location, until computerized systems were introduced in the 1970s. However, the sensors that provided information to the centralized panels were usually separate from the sensors used for feedback control. This limitation was reduced with the introduction of direct digital control in the 1990s through which sensors were used for simultaneous control and documentation. Today, it is practical to have centralized building automation control systems that focus on thermal and lighting control and energy management (e.g., optimal stop-start cycles). However, indoor air quality control remains limited by the few types of real-time sensors available (e.g., carbon dioxide, volatile organic compounds) and their reliability. Moreover, practical methods of indoor air quality control remain limited to dilution (e.g., increased ventilation) and particulate air cleaning (filters). Currently, building codes do not permit the integration of fire and life-safety control systems with BACS or energy management systems, other than fan and damper interlock controls. As the demand for improved preparedness for extraordinary incidents increases, new sensor technology is anticipated that will allow more rapid system responses, such as zone isolation, compartmentalization, and decontamination. Also anticipated are integrated control technologies that will monitor and control for improved health, occupant performance, productivity, and security. BARRIERS TO IMPROVED BUILDING PERFORMANCE Six barriers that may obstruct consideration of IEQ in the design, construction, and operations of buildings were listed in the NORA report [28]. This section extends consideration of these barriers into a set of barriers that impede implementation of health-protective features, practices, and policies: (1) disaggregated industry, (2) lack of accountability, (3) lack of credible data, (4) inappropriate value engineering, (5) deferred maintenance and other competing strategies, and (6) concerns regarding liability.

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings Disaggregated Industry The building industry is the product of a long history and has its roots in indigenous methods. Many of the theories and practices used today to design, construct, and operate buildings have evolved from these historic processes. As a result, most of the 107 million residential and 4.7 million commercial buildings in the existing stock [21, 22] serve as their own prototypes and have their own individualized sets of goals and expectations that have been defined and modified by the stakeholders associated with them. Whether or not these goals and expectations are documented (e.g., available as plans, specifications, and operating manuals), each building’s performance is dependent on the knowledge, skills, and influences of the stakeholders. Thus, the large number and types of buildings, the diversity of their stakeholders, and their conflicting drivers present significant barriers to forming a consensus approach toward the development of health-protective features and practices for the design, construction, and maintenance of buildings in the United States. Lack of Accountability Throughout the disaggregated building industry, barriers have been established to obfuscate accountability for the performance of buildings, especially as they affect occupant health. Examples of these barriers include: Designers, contractors, and operators receive little education and training in the health sciences and therefore are not generally prepared to evaluate the health consequences of their decisions. Building codes and standards focus on design and construction, seldom address “health” issues, and are written in “prescriptive format” for ease of determining “compliance” without the need to consider health consequences. Occupant health may be explicitly excluded as an issue in contracts between owners, designers, contractors, and tenants. Occupant health is generally avoided as an issue in project documentation: permit applications, architectural programs, project specifications, commissioning documentation, certificates of substantial completion, and occupancy permits. Lack of Credible Data Financial and technical decision makers have for many years questioned the quality of data that purport to relate the benefits and costs of indoor environmental exposures to health effects. The credibility barriers include: A dearth of peer-reviewed scientific studies based on statistically valid experimental designs that test the relationships between measured indoor environmental exposures and measured health consequences. A plethora of prospective and speculative reports on the projected costs and benefits expected to be realized by improvements to indoor environmental quality. Typically, these reports are based on assumptions with questionable validity. Anecdotal reports and testimonials that claim unsubstantiated health costs and benefits associated with exposures to indoor environments. Inappropriate Value Engineering Value engineering (VE) is a process used in the private and public sectors for the purpose of identifying potential cost savings in the design and construction processes. For example, the GSA defines VE as “an organized effort directed at analyzing designed building features, systems, equipment, and material selections for the purpose of achieving essential functions at the lowest life cycle cost consistent with required performance, quality, reliability, and safety” [70]. The GSA uses VE during both the design and construction phases of a project. Value engineering, if performed appropriately, can realize significant improvements in system performance with expected beneficial health consequences. However, if value engineering is used only as a means to reduce the

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings first costs of a project, it is likely to be a significant barrier to implementation of health-protective features and practices. Deferred Maintenance and Other Competing Policies Three significant barriers to the implementation and assurance of health-protective features and practices occur during the operational phases of a building’s life: (1) premature occupancy during substantial completion, (2) occupancy during interventions, and (3) occupancy during deferred maintenance. Each of these barriers may be inadvertently or intentionally employed to reduce costs without consideration for adverse health consequences. Substantial completion is defined by the American Institute of Architects as “the stage in the progress of the Work when the Work or designated portion thereof is sufficiently complete in accordance with the Contract Documents so that the Owner can occupy or utilize the Work for its intended purpose” [71]. With regard to health-protective practices, proper execution of the Certificate of Substantial Completion is critically important, as this is the first time that occupants are exposed in the yet-to-be-completed construction. Premature occupancy at substantial completion is not an uncommon cause of adverse health effects and has been the subject of litigation cases. Commissioning and diagnostic procedures may be used to minimize the risk of premature occupancy during the substantial completion period. Furthermore, accountability for the health consequences of occupancy during substantial completion also minimizes the risks to all stakeholders. After the initial move-in period, tenant turnover (i.e., “churn rate”) may be 50 percent or more in some buildings [67]. As a result, renovations and changes in system performance occur frequently. During this period, the building owner or manager may institute proactive maintenance programs, such as preventive or predictive maintenance, rely on reactive maintenance, or do no maintenance. Moreover, this is the period when overaggressive energy management procedures or cost reductions in operations and maintenance (e.g., deferred maintenance) procedures are most likely to manifest as “building degradation,” such as insufficient ventilation or moisture incursion and subsequent mold growth [3, 25-27]. Also, at any time during its operational period, interventions may be implemented through which the building or its systems are modified to meet the desired intent. This intent may be to comply with newly defined performance criteria or to reestablish compliance with the performance criteria in the original program. In some cases these interventions may consist of repairs that have no impact on occupant exposure. However, in other cases, such as replacement of walls, HVAC ductwork, or renovations of areas, the impact on occupant exposure may be significant and may require relocation during the work. Liability Some stakeholders report that their professional liability is a significant barrier to their implementation of health-protective features and practices. Most licensed architects and engineers who are responsible for the design of buildings and facility managers who are responsible for the performance of buildings during operations choose to carry professional liability insurance. This insurance is expensive and frequently contains exclusion clauses that limit the insured to issues that can be addressed under the policy. Indoor environmental issues, generally, and health issues, specifically, are most frequently excluded from the policies. Thus, the exclusions in these policies are major barriers to implementing health-protective features and practices in the design, construction, and operation of buildings. ABOUT THE PRESENTER James E. Woods, Ph.D., P.E., Fellow ASHRAE, is the executive director of The Building Diagnostics Research Institute, Inc., Chevy Chase, Md. For more than 40 years, he has practiced, taught, and conducted research in subjects related to indoor environmental quality, human responses, energy utilization, and productivity in office buildings, public assembly and monumental buildings, hospitals, schools, residences, laboratories, and

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Implementing Health-Protective Features and Practices in Buildings: Workshop Proceedings commercial aircraft. Results from these studies have been reported in more than 150 technical papers, six books, and two patents. He recently served as chairman of the ASHRAE Presidential Ad Hoc Committee on Building Health and Safety Under Extraordinary Incidents, and is now serving as an ASHRAE representative to The Infrastructure Security Partnership (TISP) Steering Committee. REFERENCES 1. Maslow, A.H. 1968. Toward a Psychology of Being. New York, N.Y.: Van Nostrand. 2. World Health Organization. 1946. Constitution. Geneva: WHO. 3. U.S. General Accounting Office. 2003. High-Risk Series: Federal Real Property. GAO-03-122. Washington, D.C.: GAO. http://www.gao.gov/cgi-bin/getrpt?GAO-03-122. 4. International Code Council. 2003. International Building Code. Falls Church, Va.: ICC. http://www.iccsafe.org. 5. National Fire Protection Association. 2003. National Electric Code. 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