There have been few recent studies demonstrating a definitive association between the transmission of airborne infections and the ventilation of buildings. The severe acute respiratory syndrome (SARS) epidemic in 2003 and current concerns about the risk of an avian influenza (H5N1) pandemic, have made a review of this area timely. We searched the major literature databases between 1960 and 2005, and then screened titles and abstracts, and finally selected 40 original studies based on a set of criteria. We established a review panel comprising medical and engineering experts in the fields of microbiology, medicine, epidemiology, indoor air quality, building ventilation, etc. Most panel members had experience with research into the 2003 SARS epidemic. The panel systematically assessed 40 original studies through both individual assessment and a 2-day face-to-face consensus meeting. Ten of 40 studies reviewed were considered to be conclusive with regard to the association between building ventilation and the transmission of airborne infection. There is strong and sufficient evidence to demonstrate the association between ventilation, air movements in buildings and the transmission/spread of infectious diseases such as measles, tuberculosis, chickenpox, influenza, smallpox and SARS. There is insufficient data to specify and quantify the minimum ventilation requirements in hospitals, schools, offices, homes and isolation rooms in relation to spread of infectious diseases via the airborne route. PRACTICAL IMPLICATION: The strong and sufficient evidence of the association between ventilation, the control of airflow direction in buildings, and the transmission and spread of infectious diseases supports the use of negatively pressurized isolation rooms for patients with these diseases in hospitals, in addition to the use of other engineering control methods. However, the lack of sufficient data on the specification and quantification of the minimum ventilation requirements in hospitals, schools and offices in relation to the spread of airborne infectious diseases, suggest the existence of a knowledge gap. Our study reveals a strong need for a multidisciplinary study in investigating disease outbreaks, and the impact of indoor air environments on the spread of airborne infectious diseases.

Role of ventilation in airborne transmission of infectious agents in the built environment - a multidisciplinary systematic review.

This paper reviews current literature on the associations of ventilation rates and carbon dioxide concentrations in non-residential and non-industrial buildings (primarily offices) with health and other human outcomes. Twenty studies, with close to 30,000 subjects, investigated the association of ventilation rates with human responses, and 21 studies, with over 30,000 subjects, investigated the association of carbon dioxide concentration with these responses. Almost all studies found that ventilation rates below 10 Ls -1 per person in all building types were associated with statistically significant worsening in one or more health or perceived air quality outcomes. Some studies determined that increases in ventilation rates above 10 Ls -1 per person, up to approximately 20 Ls -1 per person, were associated with further significant decreases in the prevalence of SBS symptoms or with further significant improvements in perceived air quality. The carbon dioxide studies support these findings. About half of the carbon dioxide studies suggest that the risk of sick building syndrome symptoms continued to decrease significantly with decreasing carbon dioxide concentrations below 800 ppm. The ventilation studies reported relative risks of 1.5 - 2 for respiratory illnesses and 1.1 - 6 for sick building syndrome symptoms for low compared to high ventilation rates.

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Association of ventilation rates and CO2 concentrations with health and other responses in commercial and institutional buildings.

Photocatalytic purification of volatile organic compounds in indoor air: A literature review

The scientific literature through 2005 on the effects of ventilation rates on health in indoor environments has been reviewed by a multidisciplinary group. The group judged 27 papers published in peer-reviewed scientific journals as providing sufficient information on both ventilation rates and health effects to inform the relationship. Consistency was found across multiple investigations and different epidemiologic designs for different populations. Multiple health endpoints show similar relationships with ventilation rate. There is biological plausibility for an association of health outcomes with ventilation rates, although the literature does not provide clear evidence on particular agent(s) for the effects. Higher ventilation rates in offices, up to about 25 l/s per person, are associated with reduced prevalence of sick building syndrome (SBS) symptoms. The limited available data suggest that inflammation, respiratory infections, asthma symptoms and short-term sick leave increase with lower ventilation rates. Home ventilation rates above 0.5 air changes per hour (h−1) have been associated with a reduced risk of allergic manifestations among children in a Nordic climate. The need remains for more studies of the relationship between ventilation rates and health, especially in diverse climates, in locations with polluted outdoor air and in buildings other than offices.

Practical Implications
Ventilation with outdoor air plays an important role influencing human exposures to indoor pollutants. This review and assessment indicates that increasing ventilation rates above currently adopted standards and guidelines should result in reduced prevalence of negative health outcomes. Building operators and designers should avoid low ventilation rates unless alternative effective measures, such as source control or air cleaning, are employed to limit indoor pollutant levels.

Ventilation rates and health: multidisciplinary review of the scientific literature

■ Abstract Theoretical considerations and empirical data suggest that existing technologies and procedures can improve indoor environments in a manner that significantly increases productivity and health. The existing literature contains moderate to strong evidence that characteristics of buildings and indoor environments significantly influence rates of communicable respiratory illness, allergy and asthma symptoms, sick building symptoms, and worker performance. Whereas there is considerable uncertainty in the estimates of the magnitudes of productivity gains that may be obtained by providing better indoor environments, the projected gains are very large. For the United States, the estimated potential annual savings and productivity gains are $6 to $14 billion from reduced respiratory disease, $1 to $4 billion from reduced allergies and asthma, $10 to $30 billion from reduced sick building syndrome symptoms, and $20 to $160 billion from direct improvements in worker performance that are unrelated to health. Productivity gains that are quantified and demonstrated could serve as a strong stimulus for energy efficiency measures that simultaneously improve the indoor environment.

Health and productivity gains from better indoor environments and their relationship with building energy efficiency

The existing literature contains strong evidence that characteristics of buildings and indoor environments significantly influence rates of respiratory disease, allergy and asthma symptoms, sick building symptoms, and worker performance. Theoretical considerations, and limited empirical data, suggest that existing technologies and procedures can improve indoor environments in a manner that significantly increases health and productivity. At present, we can develop only crude estimates of the magnitude of productivity gains that may be obtained by providing better indoor environments; however, the projected gains are very large. For the U.S., we estimate potential annual savings and productivity gains of $6 billion to $19 billion from reduced respiratory disease; $1 billion to $4 billion from reduced allergies and asthma, $10 billion to $20 billion from reduced sick building syndrome symptoms, and $12 billion to $125 billion from direct improvements in worker performance that are unrelated to health. Sample calculations indicate that the potential financial benefits of improving indoor environments exceed costs by a factor of 18 to 47. The policy implications of the findings are discussed and include a recommendation for additional research.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1600-0668.1997.t01-1-00002.x

Arthur H. Rosenfeld

Papers

Estimates of Improved Productivity and Health from Better Indoor Environments