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    Indoor Air

    Introduction: new challenges for the health professional

    How to Use This Booklet

    Diagnostic Quick Reference: a Cross-reference from symptoms to pertinent sections of

    this booklet

    Diagnostic Checklist: additional questions for use in patient intake and medical history

    Environmental Tobacco Smoke (ETS): impacts on both adults and children; EPA riskassessment findings

    Other Combustion Products: carbon monoxide poisoning, often misdiagnosed as cold

    or flu; respiratory impact of pollutants from misuse of malfunctioning combustion devices

    Carbon Monoxide (CO)

    Nitrogen dioxide and Sulfur dioxide

    Animal Dander, Molds, Dust Mites, Other Biologicals: a contributing fac tor in

    building-related health complaints

    Tuberculosis

    Legionnaires Disease

    Allergic Reactions

    Hypersensitivity Pneumonitis

    Humidifer Fever

    Mycotoxins

    Volatile Organic Compounds (VOCs): common household and office products are

    frequent sources

    Formaldehyde

    Pesticides

    Heavy Metals: Airborne Lead and Mercury Vapors: lead dust from old paint; mercury

    exposure from some paints and certain religious uses

    Airborne Lead

    Mercury Vapor

    Sick Building Syndrome (SBS): what is it; what it isn't; what health care professionals

    can do

    Two Long-Term Risks: Asbestos and Radon: two highly publicized carcinogens in

    the indoor environment

    Asbestos

    Radon

    Questions That May Be Asked: current views on multiple chemical sensitivity, clinical

    ecologists, ionizers and air cleaners, duct cleaning, carpets and plants

    What is "multiple chemical sensitivity" or "total allergy"?

    Who are "clinical ecologists"?What are ionizers and other ozone generating air cleaners?

    Can other air cleaners help?

    Should I have my ducts cleaned?

    Can carpet make people sick?

    Can plants control indoor air pollution?

    For Assistance and Additional Information: resources for both health professionals and

    patients

    References

    Co-sponsored by: The American Lung

    Association (ALA), The Environmental

    Protection Agency (EPA), The Consumer

    Product Safety Commission (CPSC), and

    The American Medical Association (AMA)

    PDF Version (PDF, 33 pp., 224 K, about PDF)

    Disclaimer

    This document may be reproduced without change, in whole o r in part, without permission, except for use as advertising material or product

    endorsement. Any such reproduction should credit the American Lung Association, the American Medical Association, the U.S. Consumer

    Product Safety Commission, and the U.S. Environmental Protection Agency. The user of a ll or any part of this document in a deceptive or

    inaccurate manner or for purposes of endorsing a particular product may be subject to appropriate legal action. Information provided in this

    document is based upon current scientific and technical understanding of the issues presented and agency approval is limited to the

    jurisdictional boundaries established by the statutes governing the co-authoring agencies. Following the advice given will not necessarily

    provide complete protection in all situations or against all health hazards that may be caused by indoor air pollution.

    Acknowledgments

    The sponsors thank the following people for the time and effort contributed to the creation of this publication: Steven Colome, Ph.D.,

    Integrated Environmental Services, Irvine, CA; Robert J. McCunney, M.D., University Medical Center, Boston, MA; Jonathan M. Samet,

    M.D., University of New Mexico, Albuquerque, NM; David Swankin, Esq., Swankin and Turner, Washington, DC.

    Appreciation is also extended to the many additional reviewers who contributed their valuable expertise.

    Introduction

    Indoor Air Pollution: An Introduction for Health Professionals

    http://www.epa.gov/iaq/pubs/hpguide.htm

    troduction for Health Professionals | Indoor Air Quality | US EPA http://www.epa.gov/iaq/pubs/hpg

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    Indoor air pollution poses many challenges to the health professional. This booklet offers an overview of those challenges, focusing on

    acute conditions, with patterns that point to particular agents and suggestions for appropriate remedial action.

    The individual presenting with environmentally associated symptoms is apt to have been exposed to airborne substances originating not

    outdoors, but indoors. Studies from the United States and Europe show that persons in industrialized nations spend more than 90 percent

    of their time indoors1. For infants, the elderly, persons with chronic diseases, and most urban residents of any age, the proportion is

    probably higher. In addition, the concentrations of many pollutants indoors exceed those outdoors. The locations of highest concern are

    those involving prolonged, continuing exposure - that is, the home, school, and workplace.

    The lung is the most common site of injury by airborne pollutants. Acute effects, however, may also include non-respiratory signs and

    symptoms, which may depend upon toxicological characteristics of the substances and host-related factors.

    Heavy industry-related occupational hazards are generally regulated and likely to be dealt with by an on-site or company physician or other

    health personnel2. This booklet addresses the indoor air pollution problems that may be caused by contaminants encountered in the daily

    lives of persons in their homes and offices. These are the problems more likely to be encountered by the primary health care provider.

    Etiology can be difficult to establish because many signs and symptoms are nonspecific, making differential diagnosis a distinct challenge.

    Indeed, multiple pollutants may be involved. The challenge is further compounded by the similar manifestations of many of the pollutants

    and by the similarity of those effects, in turn, to those that may be associated with allergies, influenza, and the common cold. Many effects

    may also be associated, independently or in combination with, stress, work pressures, and seasonal discomforts.

    Because a few prominent aspects of indoor air pollution, notably environmental tobacco smoke and "sick building syndrome," have been

    brought to public attention, individuals may volunteer suggestions of a connection between respiratory or other symptoms and conditions in

    the home or, especially, the workplace. Such suggestions should be seriously considered and pursued, with the caution that such attention

    could also lead to inaccurate attribution of effects. Questions listed in t he diagnostic leads sections will help determine the cause of the

    health problem. The probability of an etiological association increases if the individual can convincing ly relate the disappearance or

    lessening of symptoms to being away from the home or workplace.

    How To Use This Booklet

    The health professional should use this booklet as a tool in d iagnosing an individual's signs and symptoms that could be related to an

    indoor air pollution p roblem. The document is organized according to pollutant or pollutant group. Key signs and symptoms from exposure to

    the pollutant(s) are listed, with diagnostic leads to he lp determine the cause of the health problem. A quick reference summary of this

    information is included in this booklet. Remedial action is suggested, with comment providing more detailed information in each section.

    References for information included in each section are listed at the end of this document.

    It must be noted that some of the signs and symptoms noted in the text may occur only in association with significant exposures, and that

    effects of lower exposures may be milder and more vague, unfortunately underscoring the diagnostic challenge. Further, signs and

    symptoms in infants and children may be atypical (some such departures have been specifically noted).

    The reader is cautioned that this is not an all-inclusive reference, but a necessarily selective survey intended to suggest the scope of the

    problem. A detailed medical history is essential, and the diagnostic checklist may be helpful in this regard. Resolving the problem may

    sometimes require a multi-disciplinary approach, enlisting the advice and assistance of others outside the medical profession. Thereferences cited throughout and the For Assistance and Additional Information section will provide the reader with additional information.

    Diagnostic Quick Reference

    Signs and Symptoms Environmental

    Tobacco Smoke

    Other Combustion

    Products

    Biological

    Pollutants

    Volatile

    Organics

    Heavy

    Metals

    Sick Building

    Syndrome

    Respiratory

    Rhinitis, nasal

    congestion

    Yes Yes Yes Yes NO Yes

    Epistaxis No No No Yes1

    No No

    Pharyngitis, cough Yes Yes Yes Yes No Yes

    Wheezing, worseningasthma

    Yes Yes No Yes No Yes

    Dyspnea Yes2

    No Yes No No Yes

    Severe lung disease No No No No No Yes3

    Other

    Conjunctival irritation Yes Yes Yes Yes No Yes

    Headache or dizziness Yes Yes Yes Yes Yes Yes

    Lethargy, fatigue,

    malaise

    No Yes4

    Yes5

    Yes Yes Yes

    troduction for Health Professionals | Indoor Air Quality | US EPA http://www.epa.gov/iaq/pubs/hpg

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    Nausea, vomiting,

    anorexia

    No Yes4

    Yes Yes Yes No

    Cognitive impairment,