Verdibasert ventilasjonHealthVent

Indoor climate, humans and viruses - risk assessments and measures?

Jan Vilhelm BakkeRetired physician from the Labor Inspectorate

Vintermøte 2020Beitostølen

Norsk Selskap for Farmakologi og Toksikologi

Helserådet 20-14

For Helsedirektoratet og Arbeidstilsynet 2014

Bakke JV. Samfunnskostnader ved dårlig inneklima i Norge. Helserådet 20-14. Kan lastes ned fra http://www.helsebiblioteket.no/samfunnsmedisin-og-folkehelse/helseradet

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Norske sykehus har • Det dårligste inneklima for sykepleiere i Norge.• Det høyeste energiforbruket sammenlignet med

andre servicebransjer (opptil 400 KWH/m2).• De høyeste ventilasjonsratene.• Den tørreste lufta om vinteren.• Halvparten av de ressursene som trengs for

forsvarlig forvaltning drift og vedlikehold (FDV).• Uforutsigbar driftssituasjon fordi

toppdirektørene når som helst kan beslaglegge midler fra FDV-posten til annet formål.

Greenhouse gases

Carbon dioxideNitrous oxideMethane

https://energiogklima.no/klimavakten/co2-i-atmosfaeren/

• The CO2 increase has gone from 385 ppm in the mid-2000s to now 412 ppm and increased from 1 ppm/year to over 2 ppm/year during the period.

• CO2 can be "more dangerous" than previously thought (NRK 140120 https://www.nrk.no/norge/co_-kan-vere-ein-farlegare-klimagass-enn-tidlegare-trudd-1.14859497 )

• Effective measures are more important than ever. The building stock accounts for about 40% of society's real value and energy consumption.

• The EU is proposing new ventilation criteria based on health rather than the current sensory based criteria. This allows lower ventilation rates.

• It can reduce flu epidemics and the need for humidification in winter.• It is up to each country to assess, decide and implement new ventilation

requirements.• In Norway, there is now interest in implementing such requirements in

hospital buildings (Diakonhjemmet, Helse Sør-Øst, SINTEF-Byggforsk).• An expert network must be built around this work.

Merkel: I use all my energy against climate change

In her 2020 New Year's speech to the German people, Prime Minister Angela Merkel says she uses all her power to fight for control over climate change.

Global Sustainability 2018. IPCC in October. WHO in Dec. Limit global temperature rise to 1.5oC by 2030.• Halving greenhouse gas emissions by 2030 (IPCC October

2018. Global warming of 1.5°C. Summary for Policymakers) https://report.ipcc.ch/sr15/pdf/sr15_spm_final.pdf.

• Synergy with positive health effects will contribute to a positive value of more than twice the cost of implementing the necessary climate measures before 2030 (WHO 5 December 2018. COP24 special report: health and climate change ISBN 978-92-4-151497-2. © World Health Organization 2018). https://www.who.int/globalchange/publications/COP24-report-health-climate-change/en/

• Climate panel 2019: Climate change is progressing faster https://framtida.no/2019/09/25/ny-rapport-fra-klimapanelet-klimaendringane-gar-stadig-raskareSpecial Report on the Ocean and Cryosphere in a Changing Climate (24th September 2019) -https://www.ipcc.ch/srocc/download-report/

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NRK 150119, Adrian Nyhammer Olsen: Influensasyke innlagt på sykehus åttedoblet siden 2008

• Around 100,000 are diagnosed with the flu every year, and several are hospitalized as a result of the virus.

• Hauge et al. Burden of medically attended influenza in Norway 2008-2017. Influenza OtherRespiratory Viruses. 2019; 00: 1–8. https://doi.org/10.1111/irv.12627.

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• During the 2008/9 to 2016/17 seasons, an average of 2,500 were hospitalized for influenza.

• The number varied from 579 in 2008/09 to 4973 in 2016/17.

• The majority of hospital deaths were in patients 70 years and older.

Influenza in Norway

Figure: Total number of deaths per week last year and last 5 years in the age group from 65 years and older. Folkehelseinstituttet 2017 Influensasesongen i Norge 2016-17. Usually 5-10% of the population becomes ill. Mortality approximately 900 / year.In 2016-17 significant mortality week 50/2016 - week 3/2017 and week 5 and week 8/2017. This was mainly due to a higher number of deaths than expected in the elderly over 65 years.Pandemics: "Spanish Disease" in 1918-19, “Asian Disease” 1957, “Hong Kong Disease” 1968 and “Swine Flu” 2009.

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Influenza in Norway 2018-19 and earlier seasons

Percentage of physician visits for flu-like illness from week 20, 2019, season-end. https://www.fhi.no/contentassets/1350168392994b499106d8bab9bb5e2e/vedlegg/2019-20-influensaovervaking-2018-2019-uke-20.pdf

Final report https://www.fhi.no/globalassets/dokumenterfiler/rapporter/2019/influensasesongen-i-norge-2018-19_publiser.pdf

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The outbreak never exceeded medium intensity, with the level remaining for three weeks.The top was passed in week 7. As of week 40/2018, 2978 admitted patients have tested positive for influenza, corresponding to almost 4400 admissions. 99% of those admitted have been diagnosed with influenza A virus. The level has been lower than in the previous two seasons. Significantly increased vaccinationcoverage.

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Fig. 2. Weekly incidence of various respiratory pathogens, detected with real-time PCR, according to season across three consecutive years 2010–2013 (n = 8006). All agents except human rhinovirus have a strong seasonal pattern with outbreak occurring during wintertime and almost no activity during summer.

Sundell et al. J Clin Virol. 2016 Nov; 84:59-63.

Highlights

30.01.2020Sundell et al. J Clin Virol. 2016 Nov; 84:59-63.

• There is a marked seasonality of several respiratory viruses in a temperate climate.

• The impact of weather conditions on seasonality is not fully understood.

• A drop in (outdoor) temperature and vapor pressure precede the annual influenza epidemic.

• Weather conditions are important for the seasonality of other respiratory viruses.

• Human rhino- and enterovirus activity seem to be independent of climate factors.

• “However, in the temperate climate zone, outdoor RH reaches maximum levels during wintertime, suggesting that the variation regarding this parametermay not fully explain seasonality”(??? – lack of understanding of relative and absolute humidity?)

Shaman&Kohn 2009 , showed that the 31-year average prevalence and mortality of influenza fluctuated in parallel with absolute humidity and season.

Shaman et al 2009: Mean annual cycles for the best-fit SIRS (susceptible, infected, recovered, simulation) model simulations at the 5 state sites. Here, best-fit simulations were selected individually for each state based on RMS error after scaling the 31-year mean daily infection number to the 31-year mean observed daily excess P&I mortality rate. Thick blue line shows the best-fit simulation; thinner green lines show the next 9 best simulations.• Shaman J, Kohn M. Absolute humidity modulates

influenza survival, transmission, and seasonality. Proc Natl Acad Sci U S A 2009 Mar 3;106(9):3243e8.

• Shaman J, Pitzer V, Viboud C, Lipsitch M, Grenfell B. Absolute humidity and the seasonal onset of influenza in the continental US. PLoS Curr 2009;2:RRN1138.

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The sensory model, Ole Fanger, short-term testsOf people entering the room (not adapted), about 20% are dissatisfied at 7l/p/s and about 15% are dissatisfied at 10l/p/s.Adaptation is fast, after 15 minutes the feeling of bad air is gone.

CO2 = 1000 ppm equals steady state of about 7l/p/s for sedentary work.

Although those in the room do not notice the smell of bioeffluents or other troublesome odors, there is still an association between ventilation / CO2 and objective power targets for concentration, productivity and headaches.

Fanger PO. Introduction of the olf and the decipol Units to Quantfy Air Pollution Perceived by Humans indoors and outdoors. Energy and Buildings 1988; 12: 1-6.Fanger PO, Lauridsen J, Bluyssen P, Clausen G. Air Pollution Sources in Offices and Assembly Halls, Quantified by the olf Unit. Energy and Buildings, 1988; 12: 7-9.

HEAT WITH AIR?Dumb to heat the house with air: The air should be delivered "dry and cool - like white wine". Professor Povl Ole Fanger, DTU

PO Fanger (1934-2006) Healthy Buildings 2003: "Our studies indicate that lowering the air temperature 2–3 °C, for example from 23-24 ° C to 21 ° C, can improve perceived air quality by a factor of two (Wyon 2002, Fang 2004)": to keep the lower air temperature during the heating season!

Low temperature of inhaled air is important for experiencing "fresh and good air" (Toftum et al 1998, Wyon 2002, 2004, Prisoners 2006, Yang et al 2010).

Increased RF reduces the irritation of the mucous membrane, causes less asthma complaints (Jones et al. 1999), and may also lower the risk of viral infections in the winter. Therefore, the supply of air and heat should help the air to feel fresh and good without the users freezing or experiencing drafts.

Engvall 2003. Indoor Air 2003; 13: 206-11 (konveksjon el-varme og luft-til-luft vamepumper?)Fang et al Indoor Air 1998 (a); 8: 80-90Fang et al Indoor Air 1998 (b); 8: 276-284Fang et al. Indoor Air 2004; 14: 74-81.Fanger PO. Indoor Air 2006, 16, 328-34.Jones et al. Respir Med 1999; 93: 919-22.Toftum et al. Energy and Buildings 1998; 28: 15–23Wyon et al. Proceedings Indoor Air 2002Yang et al. Indoor air 2010; 20: 309-319.Wyon DP. Indoor Air 2004; 14: 92-101.

Peder Wolkoff: 40% RH? - at least> 30%!

Epidemiologic results, clinical and climate chamber studies indicate that about 40% relative humidity (RH), is better for the eye than RH less than 30% in the general population.

Wolkoff P. The mystery of dry indoor air – An overview. Review article. Environment International 2018; 121; 1058-1065.

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Local cooling installations: Some typical "fan coils" in buildings. Risk assessments?

Ceiling mounted, wall mounted and floor mounted

Refrigerators - Fan coils

Humidifier reportedly without the danger of growing up.

Nr 1 Trykk, Biri 2013 – Norway's most modern?From "printing press" to modern, clean and efficient humidification without any health risk?

Mamolen et al. Investigation of an Outbreak of “Humidifier Fever” in a Print Shop. American Journal of Industrial Medicine 1993; 23:483-490

Evaporative Humidifier Media Types

Statistics Norway 4 June 2013 Energy use in service industries, 2011, final figures

http://www.ssb.no/energi-og-industri/statistikker/entjeneste/hvert-3-aar-endelige/2013-06-04

Norwegian hospitals

Mollier diagram (Myhren & Homberg 2018)

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Line 1 describes the cooling of air from 30 °C and 65 % relative humidity to dew point temperature.Line 2 describes the cooling of air from 24 °C and 65 % relative humidity to dew point temperature.

Summertime Cooling With Ventilation Radiators

HealthVent: New framework for ventilation in the EUThe building stock accounts for about 40% of society's real value and energy consumption.

The main elements are:• Air quality must meet WHO Air Quality Guidelines.• Source control is the primary measure to deal with indoor air pollution.• Ventilation is a complementary strategy to ensure indoor air quality.• The health-based ventilation rate for a specific building is determined by a

decision diagram proposed by the HealthVent project.• The health-based ventilation rate may not be lower than the basic ventilation.• The basic ventilation is suggested to be set at 4 l/s/person (can be set lower if

justified). • Ventilation system and health-based ventilation standards shall comply with the

framework for health-based ventilation standards.

Carrer et. al. On the Development of Health-Based Ventilation Guidelines: Principles and Framework. Int J Environ Res Public Health. 2018 Jun 28;15(7).

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Health-based ventilation requirements can now be used• ECA reports from the EU and WHO 1987-2018 (Seifert et al 1993)• Experimental exposure to laboratory animals (various findings).• The European Commission's Health Vent Project (“Health-Based Ventilation Guidelines for

Europe”) (Carrer et al 2018). From the Directorate General for Health and Consumers under the Second Program of Community Action in the Field of Health (2008–2013)).

• The EU Environment and Health Action Plan 2004-2010 and the EU Public Health Program 2007-2013. (BoD, Burden of Disease) of poor air quality. Indoor air project shows that approx. 2 million disability-adjusted life years (DALYs) are lost annually in 26 European countries due to polluted indoor air.

• France's 2004 costs are estimated at 20 billion euros in 2004 (Boulanger et al 2017).

• Carrer et. al. On the Development of Health-Based Ventilation Guidelines: Principles and Framework. Int J Environ Res Public Health. 2018 Jun 28;15(7).

• Carrer et al. What does the scientific literature tell us about the ventilation–health relationship in public and residential buildings? Build. Environ. 2015, 94, 273–286.

• Seifert et al. Acritical review of criteria and procedures for developing indoor air quality guidelines and standards. Proc. Indoor Air 1993, 3, 465–470.

• WHO Europe 2000. Air Quality Guidelines for Europe. Second Edition. • Wierzbicka et al. Healthy Indoor Environments: The Need for a Holistic Approach. Int. J. Environ. Res. Public

Health 2018, 15, 1874; doi:10.3390/ijerph15091874.

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Current IAQ norms (the numbers in brackets refer to the measurement times the average values apply)

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Ventilation as a secondary strategy for controlling IAQ - source control is most effective

• Source control is most effective in controlling IAQ (Indoor Air Quality)• Health-based ventilation requires that all other means of controlling

pollution are first implemented, both inside and outside.• It is "just one air" - the air around the buildings and the indoor

environment is one continuum that should be subject to the same regulations and requirements as postulated by WHO 2000.

• Assume the following:• The guidelines are based on established norms that reduce health risks.• The guidelines recognizes that ventilation is a subordinate strategy to improve IAQ

after pollution sources are controlled by other means.• The guidelines defines the "basic ventilation" which must always remove emissions

from humans (bioeffluents) and finally the requirements for the specific "health-based ventilation rate" for a particular building.

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Decision diagram to derive adequate health-based ventilation rate for a specific building (Carrer et al 2018).• Is outdoor air OK?• Indoor air pollution. Must build on

national assessments from several different countries.

• With full control of all contaminants, health-based basic ventilation are set to 4 l/person/ second. If not, it must be higher.

• The premise is also climate installations without pollution (Bluyssen et al 2003).

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May be good for indoor climate and health1. Outdoor temperature-adjusted temperature and ventilation

requirements. 2. Low air velocities down to 0.05 m/s. Increasing air velocities 0.07 - 0.15

m/s do not produce a sense of "draft" but of reduced temperature (Bakke et al. Indoor Air 2008; 18: 131-143).

3. Clean heating - usually as low temperature heat on large surfaces - air should be supplied "dry(?) and cool". Radiant heat can maintain operative temperature at lower air temperature.

4. Maximum self-control of windows, sun protection, ventilation, temperature and lighting - motivates for higher acceptance.

5. Allowing the temperature to fluctuate can be healthy - hardly good with slightly elevated temperature and monotonous thermal conditions in time and space.

6. Humidification when absolutely necessary, only what is needed, where it is needed and with "foolproof" installations that are easy to operate.

Interessert i mer informasjon?

Kontakt:

• Sverre Holøs, SINTEF-Byggforsk, tlf 907 95 424

• Carsten Rønning, Diakonhjemmet, tlf 995 13 262