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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Microbiomes of the

Built Environment

A RESEARCH AGENDA FOR INDOOR MICROBIOLOGY,
HUMAN HEALTH, AND BUILDINGS

Committee on Microbiomes of the Built Environment:
From Research to Application

Board on Life Sciences

Board on Environmental Studies and Toxicology

Board on Infrastructure and the Constructed Environment

Division on Earth and Life Studies

Health and Medicine Division

Division on Engineering and Physical Sciences

National Academy of Engineering

A Consensus Study Report of

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THE NATIONAL ACADEMIES PRESS
Washington, DC
www.nap.edu

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001

This activity was supported by Grant No. 2014-13628 from the Alfred P. Sloan Foundation, a grant from the Gordon and Betty Moore Foundation, Grant No. NNX16AC85G from the National Aeronautics and Space Administration, Contract No. HHSN263201200074I with the National Institutes of Health, Contract No. EP-C-14-005/0007 with the U.S. Environmental Protection Agency, and with additional support from the National Academy of Sciences Cecil and Ida Green Fund. Any opinions, findings, conclusions, or recommendations expressed in this publication do not necessarily reflect the views of any organization or agency that provided support for the project.

International Standard Book Number-13: 978-0-309-44980-9
International Standard Book Number-10: 0-309-44980-4
Digital Object Identifier: https://doi.org/10.17226/23647
Library of Congress Control Number: 2017952589

Additional copies of this publication are available for sale from the National Academies Press, 500 Fifth Street, NW, Keck 360, Washington, DC 20001; (800) 624-6242 or (202) 334-3313; http://www.nap.edu.

Copyright 2017 by the National Academy of Sciences. All rights reserved.

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Suggested citation: National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: https://doi.org/10.17226/23647.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

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The National Academy of Sciences was established in 1863 by an Act of Congress, signed by President Lincoln, as a private, nongovernmental institution to advise the nation on issues related to science and technology. Members are elected by their peers for outstanding contributions to research. Dr. Marcia McNutt is president.

The National Academy of Engineering was established in 1964 under the charter of the National Academy of Sciences to bring the practices of engineering to advising the nation. Members are elected by their peers for extraordinary contributions to engineering. Dr. C. D. Mote, Jr., is president.

The National Academy of Medicine (formerly the Institute of Medicine) was established in 1970 under the charter of the National Academy of Sciences to advise the nation on medical and health issues. Members are elected by their peers for distinguished contributions to medicine and health. Dr. Victor J. Dzau is president.

The three Academies work together as the National Academies of Sciences, Engineering, and Medicine to provide independent, objective analysis and advice to the nation and conduct other activities to solve complex problems and inform public policy decisions. The National Academies also encourage education and research, recognize outstanding contributions to knowledge, and increase public understanding in matters of science, engineering, and medicine.

Learn more about the National Academies of Sciences, Engineering, and Medicine at www.nationalacademies.org.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

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Consensus Study Reports published by the National Academies of Sciences, Engineering, and Medicine document the evidence-based consensus on the study’s statement of task by an authoring committee of experts. Reports typically include findings, conclusions, and recommendations based on information gathered by the committee and the committee’s deliberations. Each report has been subjected to a rigorous and independent peer-review process and it represents the position of the National Academies on the statement of task.

Proceedings published by the National Academies of Sciences, Engineering, and Medicine chronicle the presentations and discussions at a workshop, symposium, or other event convened by the National Academies. The statements and opinions contained in proceedings are those of the participants and are not endorsed by other participants, the planning committee, or the National Academies.

For information about other products and activities of the National Academies, please visit www.nationalacademies.org/about/whatwedo.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

COMMITTEE ON MICROBIOMES OF THE BUILT ENVIRONMENT: FROM RESEARCH TO APPLICATION

Committee Members

JOAN WENNSTROM BENNETT (Chair), Rutgers University

JONATHAN ALLEN, Lawrence Livermore National Laboratory

JEAN COX-GANSER, National Institute for Occupational Safety and Health

JACK GILBERT, University of Chicago

DIANE GOLD, Brigham and Women’s Hospital, Harvard Medical School, and Harvard T.H. Chan School of Public Health

JESSICA GREEN, University of Oregon

CHARLES HAAS, Drexel University

MARK HERNANDEZ, University of Colorado Boulder

ROBERT HOLT, University of Florida

RONALD LATANISION, Exponent, Inc.

HAL LEVIN, Building Ecology Research Group

VIVIAN LOFTNESS, Carnegie Mellon University

KAREN NELSON, J. Craig Venter Institute

JORDAN PECCIA, Yale University

ANDREW PERSILY, National Institute of Standards and Technology

JIZHONG ZHOU, University of Oklahoma

Project Staff

KATHERINE BOWMAN, Study Director and Senior Program Officer, Board on Life Sciences

ELIZABETH BOYLE, Program Officer, Board on Environmental Studies and Toxicology

DAVID A. BUTLER, Scholar, Health and Medicine Division

ANDREA HODGSON, Postdoctoral Fellow, Board on Life Sciences

JENNA OGILVIE, Research Associate, Board on Life Sciences

CAMERON OSKVIG, Director, Board on Infrastructure and the Constructed Environment

PROCTOR REID, Director, National Academy of Engineering Program Office

FRANCES SHARPLES, Director, Board on Life Sciences

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

Consultants

RONA BRIERE, Editor

HELAINE RESNICK, Editor

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

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Acknowledgments

This Consensus Study Report was reviewed in draft form by individuals chosen for their diverse perspectives and technical expertise. The purpose of this independent review is to provide candid and critical comments that will assist the National Academies of Sciences, Engineering, and Medicine in making each published report as sound as possible and to ensure that it meets the institutional standards for quality, objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process.

We thank the following individuals for their review of this report:

William P. Bahnfleth, The Pennsylvania State University

Rita R. Colwell, University of Maryland, College Park

Richard Corsi, The University of Texas at Austin

Pieter C. Dorrestein, University of California, San Diego

Peter B. Hutt, Covington & Burling LLP

Susan Lynch, University of California, San Francisco

Janet Macher, California Department of Public Health (retired)

Mihai Pop, University of Maryland, College Park

Joan B. Rose, Michigan State University

Sarah Slaughter, Built Environment Coalition

Martin Täubel, National Institute for Health and Welfare, Finland

Mary E. Wilson, Harvard T.H. Chan School of Public Health

Although the reviewers listed above provided many constructive comments and suggestions, they were not asked to endorse the conclusions or

Page viii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

recommendations of this report, nor did they see the final draft before its release. The review of this report was overseen by Michael R. Ladisch, Purdue University, and William W. Nazaroff, University of California, Berkeley. They were responsible for making certain that an independent examination of this report was carried out in accordance with the standards of the National Academies and that all review comments were carefully considered. Responsibility for the final content rests entirely with the authoring committee and the National Academies.

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

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Preface

Ours is a microbial world. Although we cannot see microbes with the naked eye, we all live with microbial consortia. The microbes that are indigenous to our bodies are an essential component of our biology. Moreover, the indoor environments in which we live also harbor a complicated constellation of microbial types. The levels of microbial diversity, and the sheer numbers of organisms, are incongruous with our visual experience, but current microbiome research is changing the way we look not only at ourselves but also at the built environments we have created. DNA sequencing technologies provide a new view of the ubiquity and diversity of microbes in our lives. In looking back on centuries of human experience with buildings, we can see that people have developed many systems that support human comfort and convenience. The vision articulated in this report is that microbiome research can guide improvements to future buildings to enhance human healthfulness.

Do we know enough to rationally manage the microbial communities around us in built environments? The answer is “no.” However, there are provocative hints that in the future, coherent management of the indoor microbiome can help prevent the spread of disease and contribute to human longevity, health, and well-being.

To produce this Consensus Study Report, the National Academies of Sciences, Engineering, and Medicine brought together a group of experts to discuss the microbial communities inside our built environments and their potential effects on human health. The committee sought to understand indoor microbiome research, a discipline that is dedicated to studying build-

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

ings, the microbial communities found inside of buildings, and the complex interactions that impact human health and well-being. Of necessity, this report touches on a number of extremely dissimilar areas of research and therefore required a committee with diverse expertise. I am grateful to the informed and insightful group of professionals who so generously shared their time and knowledge during the process of writing this report. Their collective expertise was reflective of the range of subject matter covered during our deliberations. The report also was informed by a number of excellent speakers and other participants who came to our open sessions. We thank all of these contributors for sharing their perspectives and research with us. Their contributions were invaluable in further developing our ideas and filling gaps in our expertise. In addition, we thank the report reviewers who provided insightful and instrumental feedback.

On behalf of the committee, I extend our greatest appreciation to the staff of the National Academies who worked with us throughout the process of creating this report. Without their time and guidance, this report would not have been possible. Finally, we thank the sponsors of the study for their financial support and for their astute vision of what this report could accomplish.

Joan Wennstrom Bennett, Chair
Committee on Microbiomes of the Built Environment:
From Research to Application

Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×
Page xiii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×

FIGURES

1-1 The complex interactions among human occupants, built environments, and associated microbial communities

1-2 Transport and life cycle of indoor microbes

2-1 Modes of transmission of microorganisms from the airborne environment

3-1 The influence of water chemistry and flow on the microbiome of bulk water pipes

5-1 Physical processes govern the assembly of indoor microbial communities

TABLES

2-1 Mode of Transmission for Selected Pathogens Implicated in Infections Due to Inhalation or Fomite Interactions

2-2 Associations Between Health Outcomes and Exposure to Damp Indoor Environments

Annex Table 2-1: Selected Studies on Building/Home-Based Exposure Reduction and Asthma Outcomes in Children (2000–2017)

Annex Table 2-2: Beneficial Associations of Indoor Microbiota with Asthma or Allergy Outcomes in Selected Studies Using Metagenomics, Molecular Biologic, or Culture Methods to Measure Indoor Environmental Microbiota

3-1 Buildings and Surfaces Where Viruses Have Been Detected or Survived

3-2 Home High-Touch Surfaces and Bacterial Reservoirs

3-3 Hospital High-Touch Surfaces and Bacterial Reservoirs

3-4 Environmental, Location, and Surface Parameters That May Influence Microbial Populations and Communities

3-5 Sustainable, Green, and Healthy Codes, Standards, Guidelines, and Certifications That Address Microbiome-Related Issues

3-6 WELL Building Standard Features That Address Microbiome-Related Issues

4-1 Selected Building Simulation Tools

A-1 Overview of Molecular Characterization Tools

Page xvii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Acronyms and Abbreviations

ACGIH American Conference of Governmental Industrial Hygienists
AHAM Association of Home Appliance Manufacturers
AIHA American Industrial Hygiene Association
ANSI American National Standards Institute
ASHRAE American Society of Heating, Refrigerating and Air-Conditioning Engineers
ASM American Society for Microbiology
ASTM American Society for Testing and Materials
aw water activity
BASE Building Assessment Survey and Evaluation
BOMA Building Owners and Managers Association
CADR clean air delivery rate
CBECS Commercial Buildings Energy Consumption Survey
CDC U.S. Centers for Disease Control and Prevention
CHAMPS Combined Heat, Air, Moisture, and Pollutant Simulation
CHILD Canadian Healthy Infant Longitudinal Development
CHW community health worker
CMPBS Center for Maximum Potential Building Systems
CNS central nervous system
DNA deoxyribonucleic acid
DOAS dedicated outdoor air system
Page xviii Cite
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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DOD U.S. Department of Defense
DOE U.S. Department of Energy
EBI European Bioinformatics Institute
ECHO Environmental Influences on Child Health Outcomes
ECRHS European Community Respiratory Health Survey
EPA U.S. Environmental Protection Agency
eQUEST Quick Energy Simulation Tool
ERH equilibrium relative humidity
ETS environmental tobacco smoke
FIFRA Federal Insecticide, Fungicide, and Rodenticide Act
GSA General Services Administration
HCWH Health Care Without Harm
HEPA high-efficiency particulate air (filter)
HHS U.S. Department of Health and Human Services
HUD U.S. Department of Housing and Urban Development
HVAC heating, ventilation, and air conditioning
IAPMO International Association of Plumbing and Mechanical Officials
IAQA Indoor Air Quality Association
IBPSA International Building Performance Simulation Association
ICAS Inner City Asthma Study
ICC International Code Council
ICS inhaled corticosteroid
ICU intensive care unit
IDA ICE IDA Indoor Climate and Energy simulation tool
IES Illuminating Engineering Society; also Integrated Environmental Solutions
IgCC International Green Construction Code
IICRC Institute for Inspection, Cleaning and Restoration Certification
ILFI International Living Future Institute
IPM integrated pest management
IR infrared
ISAAC International Study of Asthma and Allergies in Childhood
ISIAQ International Society of Indoor Air Quality and Climate
ISS International Space Station
ITS internally transcribed spacer
IV intravenous
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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IWBI International WELL Building Institute
LEED Leadership in Energy and Environmental Design
LPS lipopolysaccharide
MBARC-26 Mock Bacteria and ARchaea Community
MCAN Merck Childhood Asthma Network
MERCCURI Microbial Ecology Research Combining Citizen and University Researchers on ISS
MERS Middle East respiratory syndrome
MERV Minimum Efficiency Reporting Value
MIxS-BE Minimum Information about any (X) Sequence-extension for the Built Environment
MoBE Microbiomes of the Built Environment
mRNA messenger ribonucleic acid
MRSA methicillin-resistant Staphylococcus aureus
MSSA methicillin-sensitive Staphylococcus aureus
MVOC microbial volatile organic compound
NASA National Aeronautics and Space Administration
NCBI U.S. National Center for Biotechnology Information
NCS National Children’s Study
NGS next-generation sequencing
NHANES National Health and Nutrition Examination Survey
NHAPS National Human Activity Pattern Survey
NHLBI National Heart, Lung, and Blood Institute
NIAID National Institute of Allergy and Infectious Diseases
NICU neonatal intensive care unit
NIEHS National Institute of Environmental Health Sciences
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
NIST National Institute of Standards and Technology
NSF National Science Foundation
OFEE Office of the Federal Environmental Executive
OSHA Occupational Safety and Health Administration
OTU operational taxonomic unit
PAMP pathogen-associated molecular pattern
PCR polymerase chain reaction
PM particulate matter
QOL quality of life
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
×
qPCR quantitative PCR
RCT randomized controlled trial
RECS Residential Energy Consumption Survey
RH relative humidity
RNA ribonucleic acid
rRNA ribosomal ribonucleic acid
SARS severe acute respiratory syndrome
SSCP single-strand conformation polymorphism analysis
SVOC semivolatile organic compound
TAB testing, adjusting, and balancing
TB tuberculosis
tRFLP terminal restriction fragment length polymorphism
TRNSYS Transient System Simulation Tool
USGBC U.S. Green Building Council
UV ultraviolet
UVGI ultraviolet germicidal irradiation
VA U.S. Department of Veterans Affairs
VOC volatile organic compound
VRE vancomycin-resistant enterococci
WHO World Health Organization
WUFI Wärme Und Feuchte Instationär
Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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Suggested Citation:"Front Matter." National Academies of Sciences, Engineering, and Medicine. 2017. Microbiomes of the Built Environment: A Research Agenda for Indoor Microbiology, Human Health, and Buildings. Washington, DC: The National Academies Press. doi: 10.17226/23647.
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People’s desire to understand the environments in which they live is a natural one. People spend most of their time in spaces and structures designed, built, and managed by humans, and it is estimated that people in developed countries now spend 90 percent of their lives indoors. As people move from homes to workplaces, traveling in cars and on transit systems, microorganisms are continually with and around them. The human-associated microbes that are shed, along with the human behaviors that affect their transport and removal, make significant contributions to the diversity of the indoor microbiome.

The characteristics of “healthy” indoor environments cannot yet be defined, nor do microbial, clinical, and building researchers yet understand how to modify features of indoor environments—such as building ventilation systems and the chemistry of building materials—in ways that would have predictable impacts on microbial communities to promote health and prevent disease. The factors that affect the environments within buildings, the ways in which building characteristics influence the composition and function of indoor microbial communities, and the ways in which these microbial communities relate to human health and well-being are extraordinarily complex and can be explored only as a dynamic, interconnected ecosystem by engaging the fields of microbial biology and ecology, chemistry, building science, and human physiology.

This report reviews what is known about the intersection of these disciplines, and how new tools may facilitate advances in understanding the ecosystem of built environments, indoor microbiomes, and effects on human health and well-being. It offers a research agenda to generate the information needed so that stakeholders with an interest in understanding the impacts of built environments will be able to make more informed decisions.

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