WHO 1999 Strategic approaches to indoor air policy-making. WHO European Centre for Environment and Health, Bilthoven 1999. http://www-euro.who.int/document/e65523.pdf.
Norbäck D. Sick building syndrome and building-related illness. In: Brune D, Gerhardsson G, Crockford G, d'Auria D, editors. The workplace. vol. 1. Fundamentals of health, safety and welfare. Geneva: International Occupational Safety and Health Information Centre (CIS), International Labour Office (ILO); Oslo: Scandinavian Science Publisher; 1997. pp. 501-532.
Mendell MJ. Nonspecific symptoms in office workers: a review and summary of the epidemiologic literature. Indoor Air 2003; 3:227-236.
Hodgson M. The sick-building syndrome. Occupational medicine: state of the art reviews 1995; 10:167-175.
Apter A, Bracker A, Hodgson M, et al. Epidemiology of the sick building syndrome. J Allergy Clin Immunol 1994; 94:277-288.
Thörn Å. The sick building syndrome: a diagnostic dilemma. Soc Sci Med 1998; 47:1307-1312.
Jaakkola JJK. The office environmental model: a conceptual analysis of the sick building syndrome. Indoor air 1998; 8(Suppl 4):7-16.
• Brauer C, Budtz-Jorgensen E, Mikkelsen S. Structural equation analysis of the causal relationship between health and perceived indoor environment. Int Arch Occup Environ Health 2008; 81:769-776.
One of few longitudinal SBS studies, but main drawback is the lack of exposure measurements.
Imai N, Imai Y, Kido Y. Psychosocial factors that aggravate the symptoms of sick house syndrome in Japan. Nurs Health Sci 2008; 10:101-109.
• Nakayama K, Morimoto K. Relationship between, lifestyle, mold and sick building syndromes in newly built dwellings in Japan. Int J Immunopathol Pharmacol 2007; 20(2 Suppl 2):35-43.
An important paper on different risk factors for SBS in Japanese dwellings.
Niemelä R, Seppänen O, Korhonen P, Reijula K. Prevalence of building-related symptoms as indicator of health and productivity. Am J Ind Med 2006; 49:819-825.
• Edvardsson BV, Stenberg B, Bergdahl J, et al. Medical and social prognosis of nonspecific building-related symptoms (Sick Building Syndrome): a follow-up study of patients previously referred to hospital. Int Arch Occup Environ Health 2008; 81:805-812.
The first study published on the prognosis for SBS patients.
Engvall K, Sandstedt E, Norrby C. The Stockholm Indoor Environment Questionnaire (SIEQ): a sociologically based tool for the assessment of indoor environment and health in dwellings. Indoor Air 2004; 14:24-33.
Andersson K. Epidemiological approach to indoor air problems. Indoor Air 1998; 8(Suppl 4):27-34.
Norbäck D, Wieslander G. Biomarkers and chemosensory irritations. Int Arch Occup Environ Health 2002; 75:298-304.
•• Lu C-Y, Ma Y-C, Lin J-M, et al. Oxidative stress associated with indoor air pollution and sick building syndrome-related symptoms among office workers in Taiwan. Inhalat Toxicol 2007; 19:57-65. A very important paper suggesting oxidative stress as one mechanism behind SBS.
A very important paper suggesting oxidative stress as one mechanism behind SBS.
• Bakke JV, Norbäck D, Wieslander G, et al. Symptoms, complaints, ocular and nasal physiological signs in university staff in relation to indoor environment-temperature and gender interactions. Indoor Air 2008; 18:131-143.
A study suggesting that energy saving by reducing the night temperature may cause SBS.
• Wolkoff P. 'Healthy eye' in office like environments. Environ Int 2008; 34:1204-1214.
An extensive and updated review on personal and environmental risk factors for ocular symptoms and signs.
Seppänen OA, Fisk WJ. Summary of human responses to ventilation. Indoor Air 2004; 14(Suppl 7):102-118.
Wargocki P, Sundell J, Bischof W, et al. Ventilation and health in nonindustrial indoor environments: report from a European Multidiciplinary Scientific Consensus Meeting (EUROVENT). Indoor Air 2002; 12:113-128.
• Norbäck D, Nordström K. Sick building syndrome in relation to air exchange rate, CO₂, room temperature and relative air humidity in university computer classrooms: an experimental study. Int Arch Occup Environ Med 2008; 82:21-30.
One of the larger studies on associations between ventilation flow and SBS in classrooms.
Bornehag CG, Blomquist G, Gyntelberg F, et al. Dampness in buildings and health: Nordic interdisciplinary review of the scientific evidence on associations between exposure to 'dampness' in buildings and health effects (NORDDAMP). Indoor Air 2001; 11:72-86.
Kubo T, Mizoue T, Ide R, et al. Visual display terminal work and sick building syndrome: the role of psychosocial distress in the relationship. J Occup Health 2006; 48:107-112.
• Sunesson A-L, Rosen I, Stenberg B, Sjöström M. Multivariate evaluation of VOCs in buildings where people with nonspecific building-related symptoms perceive health problems and in buildings where they do not. Indoor Air 2008; 18:383-391. One of few studies available on associations between patterns of VOC in offices and SBS.
One of few studies available on associations between patterns of VOC in offices and SBS.
•• Buchanan ISH, Mendell MJ, Mirer AG, Apte MG. Air filter materials, outdoor ozone and building-related symptoms in the BASE study. Indoor Air 2008; 18:144-155.
Very relevant study on the mechanisms behind for ozone-related SBS.
• Apte MG, Buchanan ISH, Mendell MJ. Outdoor ozone and building-related symptoms in the BASE study. Indoor Air 2008; 18:156-170.
An important study linking the exposure to ozone with SBS.
Bornehag CG, Sundell J, Weschler CJ, et al. The association between asthma and allergic symptoms in children and phthalates in house-dust: a nested case-control study. Environ Health Perspect 2004; 112:1393-1397.
Allermann L, Meyer HW, Poulsen OM, et al. Inflammatory potential of dust from schools and building related symptoms. Occup Environ Med 2003; 60:E5.
• Allermann L, Pejtersen J, Gunnarsen L, Poulsen OM. Building-related symptoms and inflammatory potential of dust from office buildings. Indoor Air 2007; 17:458-467.
An important study linking the inflammatory potential of office dust with SBS.
• Jaakkola MS, Yang L, Ieromnimon A, Jaakkola JJ. Office work exposure (corrected) and respiratory and sick building syndrome symptoms. Occup Environ Med 2007; 64:178-184.
A study verifying previous studies showing associations between SBS, paper dust exposure and emissions from office equipment.
Stenberg B, Wall S. 'Why do women report sick building symptoms more often than men?'. Soc Sci Med 1995; 40:491-502.
Brasche S, Bullinger M, Morfeld M, et al. Why do women suffer from sick building syndrome more often than men? Subjective higher sensitivity versus objective causes. Indoor Air 2001; 11:217-222.
Björnsson E, Janson C, Norbäck D, Boman G. Symptoms related to the Sick Building Syndrome in a general-population sample: associations with atopy, bronchial hyperresponsiveness and anxiety. Int J Tuberc Lung Dis 1998; 2:1023-1028.
Muzi G, dell'Omo M, Abbritti G, et al. Objective assessment of ocular and respiratory alternations in employees in a sick building. Am J Ind Med 1998; 34:79-88.
• Bakke JV, Wieslander G, Norbäck D, Moen BE. Atopy, symptoms and indoor environmental perceptions, tear film stability, nasal patency and lavage biomarkers in university staff. Int Arch Occup Environ Med 2008; 81:861-874. A novel study evaluating associations between different definitions of atopy and SBS.
A novel study evaluating associations between different definitions of atopy and SBS.
Berglund B, Gunnarsson G. Relationships between occupant personality and the sick building syndrome explored. Indoor Air 2000; 10:152-169.
• Gomzi M, Bobic J, Radosevic-Vidacek B, et al. Sick building syndrome: psychological, somatic and environmental determinants. Arch Environ Occup Health 2007; 62:147-155.
A combined study on SBS in relation to ventilation flow and psychosocial work environment.
Runeson R, Norback D, Stattin H. Symptoms and sense of coherence: a follow-up study of personnel from workplace buildings with indoor air problems. Int Arch Occup Environ Health 2003; 76:29-38.
Runeson R, Norback D, Klinteberg B, Edling C. The influence of personality, measured by the Karolinska Scale of Personality (KSP), on symptoms among subjects in suspected sick buildings. Indoor Air 2004; 14:394-404.
• Runeson R, Wahlstedt K, Norbäck D. Projective drawings for assessing stress among subjects with medical symptoms compatible with sick building syndrome, and validation of a modified version of the stress load index from drawing personality profile: a pilot study. Perceptual Motor Skills 2007; 104:111-122.
The first study on personality traits and SBS using a nonverbal personality test.
•• Fiedler N, Kelly-McNeil K, Ohman-Strickland P, et al. Negative affect and chemical intolerance as risk factors for building related symptoms: a controlled exposure study. Psychosom Med 2008; 70:254-262.
An important study combing personality aspects with controlled exposure to VOCs.
• Bakke JV, Moen BE, Wieslander G, Norbäck D. Gender and the physical and the psychosocial work environments are related to indoor air symptoms. J Occup Environ Med 2007; 49:641-650.
A study verifying the role of both female sex and psychosocial work environment for SBS.
Runeson R, Wahlstedt K, Wieslander G, Norbäck D. Personal and psychosocial factors and symptoms compatible with sick building syndrome in the Swedish workforce. Indoor Air 2006; 16:445-453.
Norbäck D, Edling C. Environmental, occupational and personal factors related to the prevalence of sick building syndrome. Br J Ind Med 1991; 48:451-468.
Norlen U, Andersson K. An indoor climate survey of the Swedish housing stock (the ELIB study) In: Proceedings of Indoor Air'93, 6th International Conference on Indoor Air Quality and Climate, Helsinki; 1993. vol. 1. pp. 743-748.
Engvall K, Norrby C, Jeanette B, et al. Development of a multiple regression model to identify multifamily residential buildings with a high prevalence of sick building syndrome (SBS). Indoor Air 2000; 10:101-110.

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MedscapeCME encourages Authors to identify investigational products or off-label uses of products regulated by the US Food and Drug Administration, at first mention and where appropriate in the content.

Author(s)

Dan Norbäck, PhD

Associate Professor, Department of Medical Science, Occupational and Environmental Medicine, University Hospital, Uppsala University, Uppsala, Sweden

Disclosures

Disclosure: Dan Norbäck, PhD, has disclosed no relevant financial relationships.

Editor(s)

Stephen T. Holgate, MD, DSc, FRCP

Member, Infection, Inflammation, and Repair Division, School of Medicine, University of Southampton, Southampton General Hospital, Southampton, United Kingdom

Disclosures

Disclosure: Stephen T. Holgate, MD, DSc, FRCP, has disclosed that he has served as an advisor or consultant to Merck Sharp & Dohme, Ltd., Novartis Pharmaceuticals Corporation, Synergen, Roche Laboratories Inc., Laboratorios Almirall, S.A., Rotta Pharmaceuticals, and Altair Engineering, Inc. Dr. Holgate has also disclosed that he owns stock, stock options, or bonds in Synergen.

J. Andrew Grant, MD

Professor, Departments of Medicine and Microbiology-Immunology; Training Program Director in Allergy-Immunology, University of Texas Medical Branch, Galveston, Texas

Disclosures

Disclosure: J. Andrew Grant, MD, has disclosed that he has received grants for clinical research from ViroPharma Incorporated and Dyax Corp.

Nancy Otto, PharmD

Scientific Director, MedscapeCME

Disclosures

Disclosure: Nancy Otto, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

Désirée Lie, MD, MSEd

Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

Disclosures

Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

CME

An Update on Sick Building Syndrome

Authors: Dan Norbäck, PhD
CME Released: 4/24/2009
THIS ACTIVITY HAS EXPIRED FOR CREDIT
Valid for credit through: 4/24/2010

Start Activity

Target Audience and Goal Statement

This activity is intended for primary care clinicians, pulmonologists, occupational clinicians, and other clinicians who care for patients with sick building syndrome.

The goal of this activity is to review features of sick building syndrome, potential causes and remedies, and ways to recognize and prevent the condition.

Upon completion of this activity, participants will be able to:

Describe the 3 main categories of human reactions to the indoor environment
Describe recommendations for CO2 and outdoor ventilation airflow rate
Identify volatile organic compounds associated with indoor air pollution and sick building syndrome (SBS)
List lifestyle factors associated with SBS
Describe interventions that reduce the impact of SBS

Disclosures

Author(s)

Dan Norbäck, PhD

Associate Professor, Department of Medical Science, Occupational and Environmental Medicine, University Hospital, Uppsala University, Uppsala, Sweden

Disclosures

Disclosure: Dan Norbäck, PhD, has disclosed no relevant financial relationships.

Editor(s)

Stephen T. Holgate, MD, DSc, FRCP

Member, Infection, Inflammation, and Repair Division, School of Medicine, University of Southampton, Southampton General Hospital, Southampton, United Kingdom

Disclosures

Disclosure: Stephen T. Holgate, MD, DSc, FRCP, has disclosed that he has served as an advisor or consultant to Merck Sharp & Dohme, Ltd., Novartis Pharmaceuticals Corporation, Synergen, Roche Laboratories Inc., Laboratorios Almirall, S.A., Rotta Pharmaceuticals, and Altair Engineering, Inc. Dr. Holgate has also disclosed that he owns stock, stock options, or bonds in Synergen.

J. Andrew Grant, MD

Professor, Departments of Medicine and Microbiology-Immunology; Training Program Director in Allergy-Immunology, University of Texas Medical Branch, Galveston, Texas

Disclosures

Disclosure: J. Andrew Grant, MD, has disclosed that he has received grants for clinical research from ViroPharma Incorporated and Dyax Corp.

Nancy Otto, PharmD

Scientific Director, MedscapeCME

Disclosures

Disclosure: Nancy Otto, PharmD, has disclosed no relevant financial relationships.

CME Author(s)

Désirée Lie, MD, MSEd

Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

Disclosures

Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

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For Physicians

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Practical Prevention of Sick Building Syndrome

Complaints about poor indoor air quality should be considered as an early indication of disturbances in the indoor environment. Reduced room temperature and effective cleaning routines are simple means to reduce the prevalence of SBS. It is important to clean not only the floors but also other horizontal surfaces. Moreover, carpeting and other textile materials should be minimized, unless it can be clearly demonstrated that they are properly cleaned. Personal outdoor air supply rate in buildings should be kept at at least 10 l/s, which is somewhat higher than most current ventilation standards. Exposure to microorganisms, which may grow in damp houses, or be spread by air-conditioning systems, should also be minimized. Chemical emissions from building materials should be reduced by selecting low emitting materials and products. In many buildings with SBS, the reason for complaints and illness may be obvious and the problem is easily solved by simple means. In other buildings, however, the inhabitants may exhibit persisting symptoms despite various environmental improvements. There is, however, enough information available to give some general recommendations for the secondary prevention of SBS, and these recommendations are similar to those for primary prevention.

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Page 8 of 9

Conclusion

CME Information

Abstract and Introduction
Development of the Sick Building Syndrome Concept
Patients With Sick Building Syndrome
Group Investigations of Sick Building Syndrome
Physiological Methods in Epidemiological Studies
Environmental Risk Factors for Sick Building Syndrome
Personal Risk Factors for Sick Building Syndrome
Practical Prevention of Sick Building Syndrome
Conclusion

References

CME

An Update on Sick Building Syndrome

Target Audience and Goal Statement

Disclosures

Author(s)

Dan Norbäck, PhD

Editor(s)

Stephen T. Holgate, MD, DSc, FRCP

J. Andrew Grant, MD

Nancy Otto, PharmD

CME Author(s)

Désirée Lie, MD, MSEd

Accreditation Statements

For Physicians

Instructions for Participation and Credit

An Update on Sick Building Syndrome: Practical Prevention of Sick Building Syndrome

Practical Prevention of Sick Building Syndrome

Table of Contents

References

Faculty and Disclosures

Author(s)

Dan Norbäck, PhD

Editor(s)

Stephen T. Holgate, MD, DSc, FRCP

J. Andrew Grant, MD

Nancy Otto, PharmD

CME Author(s)

Désirée Lie, MD, MSEd

CME

An Update on Sick Building Syndrome

Target Audience and Goal Statement

Disclosures

Author(s)

Dan Norbäck, PhD

Editor(s)

Stephen T. Holgate, MD, DSc, FRCP

J. Andrew Grant, MD

Nancy Otto, PharmD

CME Author(s)

Désirée Lie, MD, MSEd

Accreditation Statements

For Physicians

Instructions for Participation and Credit

An Update on Sick Building Syndrome: Practical Prevention of Sick Building Syndrome

Practical Prevention of Sick Building Syndrome

Table of Contents