Sunteți pe pagina 1din 35

Respiratory Symptoms, Airway

Inflammation Level and Sick Building


Syndrome in Relation to Indoor
Environment Among Office Workers in a
Malaysian University

NAME : LIM FANG LEE


MATIRC NUMBER : GS 30336
SUPERVISOR : PROF. DR. ZAILINA HASHIM
CO-SUPERVISOR : ASS. PROF. DR. DAN NORBÄCK
DR. LESLIE THAN THIAN LONG
DR. SALMIAH BINTI M. SAID

1
Introduction
 Large proportion of working population have office
work
 Estimated annual cost of US$1.4 billion due to
excess respiratory related sick leave in office
workers (Sahakian et al., 2009)
 Respiratory health – affected by personal or
environmental factors
 Biological parameters, eg. bacteria, fungi, allergens
 Endotoxin & (1,3)-β-glucan have pro-inflammatory &
immune stimulatory properties
2
Importance of the Study
Lack of population based studies studied on:
 Prevalence of house dust mite (HDM) and
cat allergies among office workers

 Quantification of FeNO level among office


workers from tropical area

 Associations between microbial components


in indoor office environment with respiratory
symptoms, airway inflammation level, and
sick building syndrome (SBS) among office
workers
3
General Objective
To determine the association between indoor office
environmental factors, allergies and health
variables among office workers.
Indoor office environmental Health variables
factors
● Office characteristics ● Respiratory symptoms
● Office environmental parameters: ● Airway inflammation level [Fractional
- Endotoxin exhaled nitric oxide (FeNO)]
- (1,3)-β-glucan ● Sick building syndrome (SBS)
- House dust mites (HDM) allergens
(Der p 1 and Der f 1)
- Temperature
- Relative air humidity
- Carbon dioxide (CO2)
- Carbon monoxide (CO)
4
CONCEPTUAL
FRAMEWORK

5
Lung
function
Chemical [forced
expiratory
Office volume in 1 s
•TVOC
characteris (FEV1) & peak
-tics •Ozone
•C2HO flow (PEF)
•Respirable variability]
particulate Sick
•CO Inhalation building
I
•CO2 syndrome
A
Building
Q
occupants Inflammation
Asthma &
& their Physical & Immune
Responds respiratory
activities
•Temperature symptoms
•Relative humidity
Contact
•Ventilation rate Airway
•Skin Cofactors: inflammation
Outdoor •Nose Genetic • FeNO level
Environ- Biological •Eyes susceptibility
ment such as allergy
•Bacteria
(Endotoxin) Confounders:
•Fungi (1-3-β-D- •Gender
glucan) •Allergy
•House dust mites •Smoker
allergens
Key:
Variables Study variables
6
Methodology

Administrative offices in a public university, Serdang , Malaysia

May 2013 until March 2014

Cross-sectional study

Office workers who were working in the administrative offices

List of offices and list of office workers

7
Study Inclusion criteria:
Population Office
1. Equipped with MVAC system
2. Non-smoking area
3. Admin. office with min. 15 workers

Exclusion criteria:
1. Offices in laboratories and libraries (Hayleeyesus & Manaye,
2014; Righi et al., 2002)

Inclusion criteria:
Workers
1. Admin. office worker
2. Age between 18-60 years old
3. Malaysian

Exclusion criteria:
1. Women who were pregnant (Chen et al., 2008)
2. Asthma attacks two weeks before data collection (Liccardi et
al., 2006)
3. Took antihistamines, antidepressants/ beta-blockers
medications a week before data collection (Australasian Society
of Clinical Immunology and Allergy, 2013)
4. Severe dermographisms (Heinzerling et al., 2013)
8
Sample Size
Formula for one sample problem

𝑍1−𝛼/2 2 𝑃(1−𝑃)
𝑛=
𝑑2

(Lemeshow et al., 1990)

n = Required sample size


Z1-α/2 = Z statistic for a 95% confidence internal = 1.96
P = estimated prevalence or proportion
d = margin of error = 0.05

9
Total respondents
required (after
Estimated sample size calculation based on
consider 20% non-
one sample problem
response rate and
design effect)

Respiratory symptoms among workers work in office


environment
626
1.96 2 (0.2168)(0.7832)
𝑛= = 261 (Kogevinas et al., 1999)
(0.05)2

Elevated airway inflammation level among workers work in


n environment
office = Required sample size
Z1-α/2 = Z statistic for a 95% confidence internal = 1.96 404
2
P 1.96 (0.1250)(0.0.8750)
= estimated prevalence or proportion
𝑛= = 168 (Moen et al., 2012)
d =(0.05)
margin
2 of error = 0.05

SBS symptoms among workers work in office environment


1.96 2 (0.338)(0.662)
𝑛= = 343 (Fadhilah & Juliana, 2012) 825
(0.05)2

10
Invitation letter
List of offices was
Screening process was sent to offices
obtained from
for offices which full filled
registrar office
inclusion criteria

Office workers who Self-administrated


Screening process agreed & full filled questionnaire
for office workers with inclusion criteria
of the study (n = 695)

Skin prick test FeNO test Indoor office


environmental
(n = 463) (n = 460) measurements

Figure 1: Sampling method and flow process of data collection


11
Instruments

Questionnaire Skin Prick Test Kit NIOX-MINO Device


• ECRHS, ISAAC, Örebro & • Test allergic status towards • Measure airway inflammation
NIOSH IEQ Survey HDM & cat allergens level

Q-trak Vacuum Cleaner


• Measure temperature, relative • Collect settled dust for
air humidity, CO & CO2 endotoxin, β-glucan & HDM
analysis 12
Statistical Analysis
 Bivariate analysis  Multivariate analysis:
Parametric test : Two-levels multiple
 Independent- t test logistic regression
Non-parametric test: Two-levels linear
 Chi-square mixed model
 Spearman correlation
 Kendall’s tau beta
 Mann-Whitney U
 Kruskal-Wallis H

13
RESULT & DISCUSSION

14
Specific Objective:
1. To determine the prevalence of respiratory symptoms,
elevated FeNO level, SBS symptoms and allergies in
the office workers.
Figure 1: Bar chart on prevalence of airway symptoms among
office workers (n=695)
50

40
PERCENTAGE (%)

30
26.5

20 18.4
15.5 15.1

10.1 10.3 10.7


10
6.5

0
Wheeze Breathlessness Wheezing when Daytime Daytime Any daytime Nocturnal At least one
during wheeze did not have cold breathlessness at breathlessness breathlessness attacks of airway symptoms
rest after strenuous breathlessness
activity
AIRWAY SYMPTOMS 15
Figure 2: Bar Chart on Prevalence of Asthma and Rhinitis among
Office Workers (n=695)
60
53

50
PERCENTAGE (%)

40
34.3

30

22.2
20

12.2 12.2
9.6 8.8
10 8.1 7.1

ASTHMA AND RHITNIS


16
Figure 3: Pie Chart on Proportion of Subjects with Low,
Intermediate & High FeNO Levels (n=460)
7.40% (34)

18.50% > 50 ppb


(85)
25 ppb ≤ FeNO ≤ 50 ppb

< 25 ppb

74.10%
(341)

< 25 ppb 25 ≤ FeNO ≤ 50 > 50 ppb

17
Figure 4: Bar chart on prevalence of sick building syndrome
symptoms among office workers (n=695)
25
23

20

16
Percentage (%)

15
12.9 13.3
11.9

10 9.2
8.5
7.9
7.3
6 6.2
5.3 5.5
5
5 4.5
3.6
2.2 2.6
1.9

Weekly Sick Building Syndrome Symptoms 18


Figure 5: Venn diagram on distribution of subjects for house
dust mites allergy, cat allergy, self-reported seafood allergy
and self-reported pollen allergy (N=463).

HDM/ Cat
No allergy
allergy
177 (38.2%)
173 (37.4%)
41 23
(8.9%) (5.0%)
15
(3.3%)
Seafood Pollen
allergy 5 allergy
(1.1%)
18 (3.9%) 11 (2.4%)

19
Specific Objective:
2. To determine the level of indoor office environmental
parameters (endotoxin, (1,3)-β-glucan, Der p 1, Der f 1,
amount of sieved dust, temperature, relative air humidity,
carbon monoxide and carbon dioxide) in the office.

Table 1: Level of indoor office environmental parameters


Interquartile
Environmental Parameters Median Min. – Max.
range (IQR)
Concentration of Der p1 (ng/g) 556.2 205.0 267.0 – 935.4
Concentration of Der f1 (ng/g) 658.0 714.5 174.0 – 14107.0
Concentration of endotoxin
11.3 12.2 1.8 – 90.8
(EU/mg)
Concentration of (1,3)-β-glucan
62.9 36.9 27.1 – 192.4
(ng/g)
Amount of sieved dust (g) 0.95 0.6 0.1 – 2.4
Indoor temperature (ºC) 23.9 2.9 20.9 – 27.5
Indoor relative air humidity (%) 57.1 12.0 39.8 – 79.1
Indoor carbon dioxide (ppm) 543.0 267.0 397.0 – 906.0
Indoor carbon monoxide (ppm) 0.3 0.5 0.0 – 1.6
N = 70 for dust sample & n = 37 for air measurement
20
Specific Objective:
3. To study associations between respiratory symptoms,
FeNO level, and SBS symptoms with allergies among
the office workers
Figure 6: Associations between respiratory symptoms, FeNO level and
SBS symptoms with house dust mites allergy, and cat allergy

Significantly
assoc. with
FeNO level
(p<0.001)

Significantly Significantly
assoc. with most assoc. with
HDM weekly dermal
of the
respiratory & symp. (p=0.035)
symptoms Cat & weekly
(p<0.05) mucosal symp.
Allergy (p<0.001)
21
Specific Objective:
4. To determine the associations between potential
personal risk factors with respiratory symptoms,
elevated FeNO level, and SBS symptoms among the
office workers
Figure 6: Associations between personal factors with respiratory symptoms &
FeNO level (using multilevel logistic regression with mutual adjustment)

Gender
-positively ass. with
airway symptoms &
rhinitis (p<0.05)
HDM & cat
Age allergy
-negatively ass. with Positively ass. with:
rhinitis (p<0.05) -airway, asthma & rhinitis
symptoms (p<0.05)

Respiratory
symptoms

22
FeNO levels and personal factors
• Allergic to HDM or cat (p<0.001, OR=1.80, 95%CI=1.58-2.05) was
significantly associated with FeNO level but not age, gender, height body mass
index and smoking status

Figure 7: Associations between allergies and FeNO level with respiratory


symptoms (using multilevel logistic regression)

Airway
symptoms
(p<0.05)

SPT
positive &
elevated
FeNO level

Asthma
Rhinitis
symptoms
(p<0.001)
(p<0.001)
23
Figure 8: Analysis of associations between personal factors and
weekly sick building syndrome (SBS) symptoms (using multilevel
logistic regression with mutual adjustment)

Atopy & ↑ FeNO


level
-Dermal (p=0.002;
adj.OR=3.12; 95%CI=1.51-
6.48)
-Mucosal (p<0.001;
adj.OR=4.80; 95%CI=2.44) Age
Gender -Mucosal (p=0.033;
adj.OR=0.97; 95%CI=0.93-
-Dermal (p=0.040; 1.00)
adj.OR=2.17; 95%CI=1.04-4.54)
-General (p<0.001;
adj.OR=0.62; 95%CI=0.46-
0.82)

Weekly
SBS
symptoms

24
Specific Objective:
5. To study associations between respiratory symptoms,
FeNO level and SBS among the office workers with
indoor office environmental parameters and office
characteristics

25
Table 5: Multilevel logistic regression analysis of associations between
respiratory symptoms and indoor office environmental parameters
Indoor Office
Environmental Respiratory Symptoms
Parameters
(1,3)-β-glucan → Whistling/ whistling when did not have cold
(adj. OR=0.79, 95%CI=0.63-0.99)

Endotoxin → Wheeze (adj.OR=1.37, 95%CI=1.05-1.78)


→ Rhinoconjuctivitis (adj.OR=1.37, 95%CI=1.08-1.73)
Der p 1 → Wheeze (adj.OR=0.69, 95%CI=0.51-0.93)
→ At least one airway symptoms (adj.OR=0.72, 95%CI=0.55-0.92)
Der f 1 → Any daytime breathlessness (adj.OR=1.12, 95%CI=1.00-1.25)
Temperature → Rhinitis (adj.OR=0.85, 95%CI=0.74-0.97)
Relative air → Nocturnal attacks of breathlessness (adj.OR=1.92, 95%CI=1.17-3.15)
humidity
CO2 → Rhinoconjuctivitis (adj.OR=0.83, 95%CI=0.70-0.99)
CO → Rhinitis (adj.OR=0.55, 95%CI=0.31-1.00)
Each of the models was adjusted for age, gender, atopy, smoking status, any home dampness and indoor home painting in the last 12 months.
OR calculated for 10 ng/g dust increase in (1,3)-β-glucan, 10EU/mg dust increase in endotoxin, 100 ng/g increase in level of Der p1 allergen, 1000 ng/g
26
increase in level of Derf1 allergen, 10% increase in RH, 100ppm increase in CO 2 , respectively.
Respiratory symptoms and office characteristics
-Offices with age < 10 years was significantly associated with any
daytime breathlessness after adjusting for personal factors
(adj.OR=0.55, 95%CI=0.32-0.94)

FeNO level, office characteristics & indoor office


environmental measurements
-No significant associations, except for amount of sieved dust was
significantly associated with FeNO level among subjects with
atopy (adj.OR=1.53, 95%CI=1.11-2.12)

27
Table 6: Multilevel logistic regression analysis of associations between sick
building syndrome symptoms, office characteristics and indoor office
environmental parameters
Any weekly Any weekly Any weekly
dermal mucosal general
Study Variables
symptoms symptoms symptoms
OR (95%CI) OR (95%CI) OR (95%CI)
Office
Characteristics
New furniture in
the office 2.25 (1.19-4.25)* 1.46 (0.79-2.69) 1.25 (0.71-2.23)
Passive smoke in
1.39 (0.50-3.88) 2.55 (1.11-5.82)* 3.18 (1.45-6.98)**
the office
Office
measurement
Relative air
humidity 0.75 (0.46-1.23) 0.66 (0.44-0.99)* 0.87 (0.57-1.33)
Der f 1 1.19 (1.09-1.31)*** 1.19 (1.09-1.30)*** 1.14 (1.02-1.28)*
Each model was adjusted for age, gender, current smoker, any sign of home dampness, indoor home painting in the last 12 months and
offices
*p<0.05
**p<0.010
28
***p<0.001
Conclusion
 ↑ prevalence of rhinitis, HDM allergy and cat allergy
 CO2 & CO levels were within the suggested level
by local authority except for indoor temp. & RH
 Personal and indoor office environmental exposure
factors associated with health variables in workers
 Respiratory & SBS symptoms were due to allergic
inflammation (combined analysis of FeNO
measurement & SPT)
 Allergy is an independent risk factor for respiratory
symptoms, FeNO level & SBS symptoms
29
Recommendations
Future Studies
 Additional types of common allergies, eg.
indoor environmental allergens (Blomia
tropicalis, cockroach & mouse), mould,
grass, pollen allergens
 Determine possible sources of endotoxin
& HDM in office environment
 Cohort study in indoor air quality studies
is needed
30
Management of Offices
 Functional thermostat (range 24-27°C) at the air-
conditioning system

 Maintain office cleanliness:


 By frequent office cleaning
 Regular vacuum cleaning using vacuum fitted with
high efficiency particulate arrestance (HEPA) on
carpeted floor

• Regular maintenance of mechanical ventilated air-


conditioning system
 Check and clean filters and drain pans regularly
31
Individual
 Avoid eating at workstation – maintain
cleanliness of the office
 Office with centralized ventilation system
- wear sweaters/ scarf if feel indoor
temperature is too low
 Avoid smoking in the university, especially
outside/ entrance of the office

32
List of Publications
Lim, F.L., Zailina, H., Z., Than, L.T.L.,
Salmiah, M. S., Jamal Hisham, H.,
Norbӓck,D. (2015) Asthma, airway
symptoms and rhinitis in office workers in
Malaysia: Associations with house dust
mite (HDM) allergy, cat allergy and levels
of house dust mite allergens in office dust.
PLoS ONE, 10(4), e0124905.
[IF = 3.23]

33
Lim, F.L., Zailina, H., Than, L.T.L., Salmiah, M.
S., Jamal Hisham, H., Norbӓck, D. (2015)
Sick building syndrome (SBS) among office
workers in a Malaysia university –
Associations with atopy, fractional exhaled
nitric oxide (FeNO) and the office
environment. Science of the Total
Environment, 536, 353-361.
[IF=4.10]

34
Lim, F.L., Zailina, H., Than, L.T.L., Salmiah,
M. S., Jamal Hisham, H., Norbӓck, D.
(2015) Fractional exhaled nitric oxide
(FeNO) among office workers in an
academic institution, Malaysia –
Associations with asthma, allergens and
office environment. Journal of Asthma.
doi: 10.3109/02770903.2015.1077861
[IF= 1.80]

35

S-ar putea să vă placă și