Indoor Allergens

Assessing and Controlling Adverse Health Effects

Andrew M. Pope, Roy Patterson, and Harriet Burge, Editors

Committee on the Health Effects of Indoor Allergens

Division of Health Promotion and Disease Prevention

INSTITUTE OF MEDICINE

NATIONAL ACADEMY PRESS
Washington, D.C.
1993



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Indoor Allergens: Assessing and Controlling Adverse Health Effects Indoor Allergens Assessing and Controlling Adverse Health Effects Andrew M. Pope, Roy Patterson, and Harriet Burge, Editors Committee on the Health Effects of Indoor Allergens Division of Health Promotion and Disease Prevention INSTITUTE OF MEDICINE NATIONAL ACADEMY PRESS Washington, D.C. 1993

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Indoor Allergens: Assessing and Controlling Adverse Health Effects NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competencies and with regard for appropriate balance. This report has been reviewed by a group other than the authors according to procedures approved by a Report Review Committee consisting of members of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy’s 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. This project was supported by funds from the Environmental Protection Agency, National Institute of Environmental Health Sciences, National Institute of Allergy and Infectious Diseases, National Heart, Lung, and Blood Institute, and Agency for Toxic Substances and Disease Registry. Library of Congress Cataloging-in-Publication Data Indoor allergens : assessing and controlling adverse health effects / Andrew M. Pope, Roy Patterson, and Harriet Burge, editors ; (Committee on the Health Effects of Indoor Allergens, Division of Health Promotion and Disease Prevention, Institute of Medicine). p. cm. Includes bibliographical references and index. ISBN 0-309-04831-1 1. Respiratory allergy. 2. Indoor air pollution. 3. Allergens. I. Pope, Andrew MacPherson, 1950- . II. Patterson, Roy, 1926-III. Burge, Harriet. IV. Institute of Medicine (U.S.). Committee on the Health Effects of Indoor Allergens. [DNLM: 1. Hypersensitivity—complications. 2. Allergens—adverse effects. 3. Air Pollution, Indoor—prevention & control. 4. Air Pollution, Indoor—adverse effects. WA 754 I4115 1993] RC589.I53 1993 616.2’02—dc20 DNLM/DLC for Library of Congress 93-744 CIP Copyright 1993 by the National Academy of Sciences. All rights reserved. Additional copies of this book are available from the National Academy Press, 2101 Constitution Avenue, NW, Box 285, Washington, DC 20055. Call 800-624-6242 or 202-334-3313 (in the Washington Metropolitan Area). Printed in the United States of America The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatlichemuseen in Berlin.

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Indoor Allergens: Assessing and Controlling Adverse Health Effects COMMITTEE ON THE HEALTH EFFECTS OF INDOOR ALLERGENS ROY PATTERSON (Chair), Ernest S. Bazley Professor of Medicine and Chief, Division of Allergy-Immunology, Northwestern University Medical School, Chicago, Illinois HARRIET BURGE (Vice-Chair), Associate Professor of Environmental Microbiology, Harvard School of Public Health, Boston, Massachusetts REBECCA BASCOM, Associate Professor of Medicine, Division of Pulmonary and Critical Care Medicine, University of Maryland School of Medicine, Baltimore, Maryland ROBERT K. BUSH, Professor of Medicine, University of Wisconsin, Madison, and Chief, Allergy Section, William S. Middleton V.A. Hospital, Madison, Wisconsin LESLIE C. GRAMMER, Professor of Medicine, Division of Allergy-Immunology, Northwestern University Medical Center, Chicago, Illinois MICHAEL D. LEBOWITZ, Professor of Internal Medicine and Associate Director, Respiratory Sciences Center, College of Medicine, University of Arizona, Tucson FLOYD MALVEAUX, Chairman, Department of Microbiology, College of Medicine, Howard University, Washington, D.C. JOHN L. MASON, Allied Signal Aerospace Company, Palos Verdes Estates, California PHILIP R. MOREY, Manager, Indoor Air Quality Services, Clayton Environmental Consultants, A Marsh & McLennan Company, Norristown, Pennsylvania THOMAS A. W. PLATTS-MILLS, Professor of Medicine and Microbiology and Head, Division of Allergy and Clinical Immunology, University of Virginia Medical Center, Charlottesville CAROL RICE, Professor of Environmental Health, Department of Environmental Health, University of Cincinnati Medical Center, Cincinnati, Ohio LANNY J. ROSENWASSER, Head, Allergy and Clinical Immunology, National Jewish Center for Immunology and Respiratory Medicine, and Professor of Medicine and Co-Head, Division of Allergy and Immunology, University of Colorado Health Sciences Center, Denver, Colorado ABBA TERR, Clinical Professor of Medicine and Director, Allergy Clinic, Stanford University Medical Center, Stanford, California M. DONALD WHORTON, Vice President, ENSR Health Sciences, Alameda, California JAMES E. WOODS, W. E. Jamerson Professor of Building Construction, College of Architecture and Urban Studies, Virginia Polytechnic Institute and State University, Blacksburg

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Indoor Allergens: Assessing and Controlling Adverse Health Effects Ex-Officio Member and Liaison to the Institute of Medicine's Board on Health Promotion and Disease Prevention EULA BINGHAM, Professor of Environmental Health, College of Medicine, University of Cincinnati, Cincinnati, Ohio Institute of Medicine Staff Andrew M. Pope, Study Director Polly A. Buechel, Study Assistant Michael A. Stoto, Director, Division of Health Promotion and Disease Prevention Gary B. Ellis, Director, Division of Health Promotion and Disease Prevention (through 12/24/92) Linda A. DePugh, Administrative Assistant Meg Knemeyer, Financial Associate

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Indoor Allergens: Assessing and Controlling Adverse Health Effects Preface This report deals with the growing concern of many in this country about the indoor environment and its relationship to human health and comfort. Among the various health issues facing the citizens of the United States, the problem of indoor airborne allergens is one of the more serious. A high percentage of the population becomes sensitive to indoor allergens and suffers chronic or intermittent allergic disease. Most of these disease conditions can be classified as mild or moderate, but many are severe, and some are fatal. A perspective on this issue is provided by the estimated $6.2 billion annual cost of asthma-related illness in the United States. Although costs related to allergic asthma are by no means the largest component of this total, they are extensive enough to warrant attention to the role of indoor allergens in this condition. Allergic reactions to indoor allergens can produce inflammatory diseases of the eyes, nose, throat, and bronchi, which are medical problems that come under the headings of allergic conjunctivitis, allergic rhinitis, allergic asthma, and hypersensitivity pneumonitis (extrinsic allergic alveolitis) respectively. The overall objective of our committee was to provide a comprehensive evaluation of current knowledge of these allergic diseases as they relate to airborne allergens in the indoor environments, and methods for their control. The range of allergens to be found indoors is broad; it is set against the backdrop of an equally broad range of indoor environments. Our committee focused on airborne allergens, or aeroallergens, in residential, hospital, school, and office environments. We examined what is known about the adverse

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Indoor Allergens: Assessing and Controlling Adverse Health Effects effects on human health caused by indoor allergens that elicit allergic reactions, characterizing the magnitude of these problems nationally and the populations that are commonly affected. We also identified specific causative agents and their sources and reviewed testing methodologies for indoor allergens, including their applicability and interpretation. Industrial environments were addressed only to the extent that a few specific industrial chemicals have been shown to be immunogenic and provide models for potential exposures in other environments. The report does not cover indoor allergens that are not airborne, such as contact allergens that elicit a lymphocyte-mediated contact dermatitis, for example, from dyes or cosmetics. Also not discussed are allergic reactions to therapeutic drugs. A specific exclusion from the committee's scope of work was the phenomenon known as multiple chemical sensitivity (MCS). MCS was not addressed in any detail because the committee's focus was on the relationship between allergic agents and conditions mediated by the immune system. So far, scientific evidence that would support such a relationship with respect to MCS is lacking. As stated in a recent National Research Council report (NRC, 1992a, p. 138), "there is insufficient evidence to ascribe an immune etiology to this disorder." In addition, the sponsors of this project specifically excluded MCS from the charge to the committee. As this report on indoor allergens evolved, the importance of the committee's multidisciplinary structure became apparent. Engineers, aerobiologists, epidemiologists, psychologists, and physicians subspecializing in allergy, pulmonary medicine, and immunology and epidemiology interacted and communicated with enlightening candor. The result was an educational process for all involved. The resulting coordinated effort attempts to provide a comprehensive, balanced report on a complex of health issues that appear to be assuming increasing importance. The recommendations generated by the committee stand as recommendations adopted by the committee as a whole. They are thus consensus opinions developed in the best interests of the public, the health care professions, the engineers and architects concerned with the structures in which we live, and the government agencies charged with carrying out the mandates of the people. The committee's recommendations are directed broadly, rather than toward any specific agencies, institutions, or offices, because the committee was not asked by the sponsors to address this aspect of the problem and did not believe that the additional focus was necessary or appropriate. Finally, it should be noted that the conclusions and recommendations of this study are based on the knowledge and expertise available at this time. There remains a great need for research and further understanding of allergens and indoor environments. Notwithstanding such a need, it must also be emphasized that some aspects of the diseases discussed in this report cannot be altered even by major emphasis on control of indoor allergens.

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Indoor Allergens: Assessing and Controlling Adverse Health Effects For example, the rising death rate from asthma, a problem of international scope, extends beyond the issue of indoor allergens, because the severe inflammatory disease of the airways in many asthmatics often is not the result of allergen exposure. Control of severe asthma in patients with potentially fatal disease may involve addressing other problems, including psychiatric disease and socioeconomic factors such as poverty, the geographic distribution of medical care, and illicit drug use. To place too much emphasis on indoor allergens when other such major problems are present is not the intent of this report. It is our hope and intention that this report will prove a spur to action. Many of the adverse health effects resulting from occupying indoor environments can be prevented. What is needed is a plan that embraces education of health professionals, engineers, building designers, and the general public—a plan that will not only improve the quality of life for millions of allergy sufferers but that will also result in substantial savings in many areas of the nation's health care costs. Roy Patterson, M.D., Chair Harriet Burge, Ph.D., Vice-Chair Committee on the Health Effects of Indoor Allergens

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Indoor Allergens: Assessing and Controlling Adverse Health Effects Acknowledgments The committee wishes to acknowledge and express their gratitude for the support and assistance of a few very helpful and generous individuals. H. Jenny Su, Harvard School of Public Health; Thomas L. Creer, Ohio University; and Mary Kay O'Rourke, University of Arizona, prepared provocative, informative background documents for the committee. These documents were extremely valuable in generating vigorous discussion and productive thought in relevant areas. The committee also thanks Jay Slater of Children's Hospital, District of Columbia, for his assistance in sorting out the issues related to latex allergy. Jim Frazier is acknowledged for his persevering scientific curiosity, which ultimately led to the conduct of this study. The sponsors of this project are acknowledged for their assistance in providing information and guidance as well as for identifying this as an important area and requesting that the IOM conduct the study. In particular, the following sponsoring agencies and individuals are acknowledged: from the Environmental Protection Agency, Robert Axelrad and Pauline Johnston; from the National Institute on Allergy and Infectious Disease, Robert Goldstein, Eugene Zimmerman, and Marshall Plaut; from the National Heart, Lung, and Blood Institute, Suzanne Hurd; from the National Institute of Environmental Health Sciences, Kenneth Olden and C. W. Jameson; and from the Agency for Toxic Substances and Disease Registry, Barry Johnson and Stephen Von Allmen. Lastly, a debt of gratitude is owed to the IOM staff. No effort of this kind can be accomplished without the hard work and dedication of a talented staff. The committee thanks the following IOM staff members: Laura Baird, director of the IOM Library; Leah Mazade, technical editor; Polly Buechel, study assistant; Gary Ellis, former director of the Division of Health Promotion and Disease Prevention (through 12/24/92), and Andrew Pope, study director.

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Indoor Allergens: Assessing and Controlling Adverse Health Effects Contents     EXECUTIVE SUMMARY   1 1   INTRODUCTION   34     Allergens and the Indoor Environment,   37     Concepts and Definitions,   39     Scope and Organization of the Report,   42 2   MAGNITUDE AND DIMENSIONS OF SENSITIZATION AND DISEASE CAUSED BY INDOOR ALLERGENS   44     Immunologic Sensitization,   45     Diseases,   53     Conclusions and Recommendations,   83 3   AGENTS, SOURCES, SOURCE CONTROLS, AND DISEASES   86     Dust Mite, Cockroach, and Other Arthropoda,   86     Mammals and Birds,   99     Microbial Allergens,   108     Chemicals,   117     Plants and Plant Products,   125     Conclusions and Recommendations,   129 4   MECHANISMS OF IMMUNE FUNCTION   131     Response of Airway Cells and Tissues to Indoor Allergens,   133     Mediators,   144     Generation of Immune Response and Host Defense to Indoor Allergens,   146     Conclusions and Recommendations,   151

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Indoor Allergens: Assessing and Controlling Adverse Health Effects 5   MEDICAL TESTING METHODS   153     Medical History and Diagnosis,   153     Skin Tests,   160     In Vitro Diagnostic Tests,   166     Pulmonary Function Tests,   171 6   ASSESSING EXPOSURE AND RISK   185     Exposure Assessment,   185     Risk Assessment,   196     Conclusions and Recommendations,   204 7   ENGINEERING CONTROL STRATEGIES   206     Principles and Strategies,   207     Summary of Practical Control Strategies,   227     Conclusions and Recommendations,   229 8   THE ROLE OF EDUCATION   233     Educating Patients and the General Public,   233     Educating Health Care Providers,   240     Summary,   242     REFERENCES   246     ACRONYMS   281     GLOSSARY   284     COMMITTEE AND STAFF BIOGRAPHIES   293     INDEX   299

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