the cost of not resolving indoor air quality issues in homes.phdpaper2.v2

8/3/2019 The Cost of Not Resolving Indoor Air Quality Issues in Homes.phdpaper2.v2

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The cost of not resolving Indoor Air Quality

issues from the development of toxic moulds

in damp homes with a reference to

commercial and business impacts

Craig Hostland P. Eng. MBA FEC CIEC

Dr. Gordon Lovegrove P. Eng. PhD

Dr. Deborah Roberts P. Eng. PhD


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The cost of not resolving Indoor Air Quality issues from the development of

toxic moulds in damp homeswith a reference to commercial and businessimpacts

C. Hostland1, G. Lovegrove2, D. Roberts3

1PhD graduate student Civil Engineering, School of Engineering, University of British Columbia Okanagan, Kelowna, BC Canada V1V 1V7,E-mail: [email protected] Professor, School of Engineering, University of British Columbia Okanagan, Kelowna, BC Canada V1V 1V7, E-mail:[email protected] Associate Professor Associate Director: Graduate Studies and Research, , School of Engineering, University of British Columbia Okanagan,Kelowna, BC Canada V1V 1V7, E-mail: [email protected]

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Abstract

Chronic ill-health from mould development in damp home environments appears to be prevalent

in North America to the detriment of not only individuals but society as a whole. Various pilotprojects and health studies conclude that better indoor environments translate to better well-beingthrough lower incidence of ill-health and higher productivity in the workplace which result infewer doctor and emergency room visits and reduced hospital stays as well as lower direct andindirect costs to businesses. Specifically, a number of effects have been studied with toxic mouldin damp homes found to significantly increase the incidence of chronic asthma conditions with adirect and consequential impact on the health care system. Removing toxic mould in damphomes not only translates into a reduced burden on a society that funds universal health care butthis paper concludes a potentially significant net social cost/benefit by taking a proactiveapproach to addressing toxic mould in built structures. The residential toxic mould burden onNorth America health care systems is calculated to be in excess of $ 3.6 billion dollars a year.

The net social/cost benefit to the health care system alone for removing toxic moulds fromhomes to reduce medical treatment level asthma attacks has been calculated to be in excess of$145,000 per affected person over their lifetime. The real cost to society is in the hundreds ofbillions of dollars per year when the issue is expanded to include commercial, financial, andsocial based impacts. Based on results, this paper recommends further investigation intosolutions to correct this societal level crisis which are critical to the well-being of families,communities, and the North American economy at large.

Key words: Allergy, asthma, cost benefit analysis, damp environments, environmental toxinshealth care, indoor air quality, IAQ, IEQ, moisture, mold, mould, mould growth, sustainability

1 Introduction

Ill-health in homes is caused by a number of well defined indoor air quality issues with thelargest contributors being: biological agents such as toxic mould (mycotoxins, MVOCs); volatilechemicals (phenols in manufacture, pesticides); volatile organic compounds (VOCs);manufactured goods emissions [formadehyde]); radon gas; particulate matter [dust and smoke];products of combustion [pm25, CO, No2]; and external and internal noxious gases (septic [h2s],industrial, ozone producing equipment and auto [O3 and many others]). These IAQ problems areeasily avoidable if recognized by the occupant as such and dealt with promptly given adequatedirection and ways and means (Samet et al. 2003). But non-recognition and therefore non-actionis a common inhibitor in the removal of such toxins from our environment. In particular, with norecognized connection between damp buildings and mould by the current health care system,

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government in general, and an unaware public, remediating the problem source the home isnot being actively addressed. Non-action has been found to amplify the real cost to society.

A relationship between dampness and incidence of mould in homes and ill-health has been

confirmed. Moisture damage and consequent mould contamination have been commonlyreported in built structures (homes, schools, hospitals, etc) with an association betweendampness or mould and adverse health effects noted (Bernstein et al. 2008). Residential dampnessand mould are associated with substantial and statistically significant increases in bothrespiratory infections and bronchitis (Fisk WJ., 2010 p. 4). Fisk further states that effectivecontrol of dampness and mould in buildings would prevent a substantial proportion of respiratoryinfections. According to Verhoeff (1997) fungi (mould) does cause allergenic disease. Canadianhomes have a high prevalence (38%) of dampness or moulds present (Dales, 1991). US homeshave a corresponding prevalence.

The purpose of this paper is to: A) conduct a detailed literature review to confirm the impactof increased incidence of chronic health problems cross referenced to mould and dampness inNorth American homes; B) determine health and societal cost for not addressing householdmould related problems; and C) consider first step solutions to reversing the problem andaverting a deeper crisis.

A cost/ benefit analysis requires an ability to measure and quantify the impact of toxicmoulds in homes on society. This is, in part, accomplished by measuring health care costsattributable to toxic moulds in homes. Recent research provides limited but consequential

quantified statistics pertaining specifically to mould, its impact on residential occupants, and itsimpact on the North American health care system. The effects of respiratory disease and asthma,on the other hand, are well described statistically for the population at large and an associationexists between dampness and mould in homes and respiratory diseases.

The detailed literature review conducted for this paper exposes a direct relationship betweenasthma and symptoms caused by mould in indoor workplace and residential environments.Jaakkola (2002) an others attribute 21 - 35% of asthma to mould exposure in workplace andresidential studies. Further, it is found that asthma constitutes a significant percentage ofmeasured doctor and emergency room visits as well as hospital bed stays (CDC 2000, PHAC

2007). Therefore not only a direct relationship appears to connect the incidence of asthma relatedill-health to toxic mould in indoor environments but also to health care costs in a measurableway. There are a number of other indirect causal effects that as well can contribute to theincreased benefit of removing toxic moulds from homes, such as reduction in: anemia; generalmalaise; lost work days; reduced efficiency; and reduction in mental health impacts in thepopulation that will be reviewed in a further study.

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Numerous commercial environment based technical papers, regulations, and standards existfor hundreds of chemicals, noxious gases, VOCs, and biological agents; but only a few technicalpapers and no standards or regulations exist for these health hazards, let alone mould, in homesas very few jurisdictions have enacted health and safety based regulations and those who havesignificantly limit the impact of same. This information is included and assessed by comparative

method to residential environments as recommended by Fisk (2007) who suggests the exposurerisks are similar between that found in buildings and that found in homes. This paper relies onthis assertion; but the comprehensive adaptation of industry standards to residentialenvironments adjusted for conditions requires further research to ensure accuracy ofcomparatives.

The literature search on IAQ subjects other than mould such as VOCs, noxious gases,chemicals, and the literature on asthma in relation to dust mite or cockroach allergens wasspecifically excluded from this paper. The more pertinent results of the literature review areprovided below:

Table 1 SUMMARY of supporting literature review studies and research-:

indoor dampness, mold, and asthma symptoms

Study Agent of Interest Conclusions

Dales et all (1991,2008) Indoor dampness and

mould

Respiratory symptoms increase with indoor

dampness and mould

Jaakkola et al (2002) Indoor dampness and

molds in homes

Increased risk of asthma in damp or mold

containing indoor environments

CDC (2002) Prevalence of asthma

in general population

Increase in asthma prevalence from 1980

1999. Noted success in intervention programs.

Kercsmar et al (2006) Indoor dampness and

mould

Reduction of asthma symptoms after

environmental remediation

Fisk et al (2007) Indoor dampness and

mould

Association between asthma, mold and sick

buildings

Hope & Simon (2007) Indoor dampness and

mould

Respiratory symptoms with indoor dampness

and mould

Howden - Chapman Indoor dampness, Marked decrease in doctor/ hospital visits

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(2007) cold and respiratory

symptoms

after renovation

Health Canada (2007) Indoor mould Association with asthma symptoms

NYC (2008), Koskinen

et al. (1999)

Indoor damp

environments

Association with asthma, allergy, and

respiratory symptoms

Sakakian, Park, Cox-

Ganser (2008)

Indoor dampness and

mould

Association between dampness, mould, and

asthma.

Fisk et al (2010) Indoor dampness and

mould

Statistically significant increase in respiratory

infections.

Cabral (2010) Indoor dampness and

airborne fungi

Association between fungal growth and sick

houses and buildings

Pongracic et al (2010) Fungal contaminationin homes

Association with cause of poor asthma andneed for home renovations

Current knowledge supports the need to prevent damp conditions and mould growth and toremediate any fungal contamination in buildings (PHAC 2007).

2. Systematic failures in residential mould identification and ill-health

The medical systems in North America bear a large responsibility in the non-identificationof mould from damp buildings and the associated epidemic of building related ill-health in thegeneral North American population. Critically, the present health care profession is mute on theconsequential relationship between ill-health and indoor environments; as exhibited by itsabsence in medical curricula (assessing the human body independent of environment) (Wu et al,2007) and non-inclusion in standard medical assessment procedures. Data on mould relatedsickness is not routinely collected as there is no specific ICD code that defines it in the hospitaladmissions and mortality data. (PHAC 2007).

In addition, many North Americans with readily available health care actually have little

time to seek medical attention and as such do not proceed through the medical system at all, orare thwarted by waiting room line-ups and available appointment time. With or without medicaltreatment, the afflicted continue to function at a reduced rate and remain compromised whenconducting normal functions including attempting to live pain free and work at regular jobs.Some are impacted to the point of not being able to sustain normal social functions. Society isadversely impacted each time the health care system is accessed or demand is elevated due to aspecific causal effect, each time subsidized drugs and treatments are prescribed and each timesomeone loses their ambulatory abilities and health care services are called upon to assist in day-

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to-day required activities; but society is also adversely affected when the impact remains silent tothe health care system.

A review of over 500 recent studies and contact records show a high incidence of IAQ

affected occupants occur in low income rental environments (Hostland 2010). Tenant complaintsof SBS related sickness were not positively addressed by building landlords nor by the BCResidential Tenancy (RTO 2011) complaints process even when verified mould environmentswere professionally documented (Hostland 2010). Without options to move (low vacancy rate orlack of available funds to relocate) and no recourse through medical or government assistanceprograms, tenants literally remain confined to environments that make them and their childrensick - to the point of exhaustion and utter despair which leads to mental health impacts (Friedl,2009). The cycle of chronic sickness, constant trips to the emergency room and ongoing need ofsocial support is not easily broken by a system that does not recognize the plight of the workingpoor and their children.

3. Studies confirming a relation between mould and asthma

Asthma is the single most common chronic disease of childhood affecting more than threemillion children in the US (Kercsmar et al. 2006). Documented to be a by-product ofunhealthy home environments (Daisey et al. 2003; Engvall et al. 2001; Nafstad et al. 1998; Perryet al. 2003; Rosenstreigh et al. 1997; Zock et al. 2002; Zureik et al. 2002), asthma can be caused

by high levels of exposure to mould, dust mite, and cockroach (Kercsmar et al. 2006) exacerbatedby dampness and moulds in homes (Dales et al. 1991, Fisk et al. 2007,2010). The objectives of thispaper to consider the connections between toxic moulds in damp homes, the cost burden on thehealthcare system, and the net social cost/ benefit of resolving this issue proactively will beaddressed utilizing Government published hospitalization records and peer reviewed journalstudies.

Asthma based health records are well defined within the American health field but not soclearly in the Canadian health landscape, due to a number of structural differences. As such, this

paper relies on comprehensive American national asthma statistics (CDC, 2000) to support a costbenefit analysis based on a preventative health care model to bring better IAQ into homes in asustainable way in Canada and more specifically into British Columbia. Existing residentialbased research will be supplemented further with studies that focus particularly on mould typesor extent of airborne and surface dwelling toxic moulds that correlate to SBS type healthresponses in homes and commercial workplace environments which will help to provide deeperclarity and perspective that does not now exist.

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Research studies conducted to date associate mould with asthma and ill-health at astatistical level. Table 3-1 (Sahakian et al. 2008) summarizes findings with an odds ratio (O/R)of 1.1 to 4.7 with an average of 2.5 with a 95% probability of accuracy from 6 studies. The oddsratio is the ratio of the odds of an event occurring in one group to the odds of it occurring inanother group which indicates a measure of increased risk that exposure to the agent will result

in an ill-health outcome. For example a higher O/R indicates a higher risk. The term is also usedto refer to sample-based estimates of this ratio.

Table 3-2 provides an incident rate ratio of 0.6 to 8.5 from three studies.An incident rateratio in epidemiology is calculated to compare the ratio of events occurring ( ie Incidence Rate1/Incidence Rate 2). Incidence is a measure of the risk of developing some new condition withina specified period of time. Although sometimes loosely expressed simply as the number of newcases during some time period, it is better expressed as a proportion or a rate with a denominatorwith higher values indicating a higher risk of developing the condition.

Table 3-1 -- Epidemiologic studies investigating an association between indoor dampnessor mold and new-onset asthma or new-onset asthma-like symptoms that use odds ratios asa measure of risk(Sahakian et al. 2008)

Reference Study design Environmental

exposure

Health outcome Odds ratio

(95% CI)

Adults

Flodin andJnsson

Longitudinal case-control study (2065years old)

Reported workplacedampness (mold or moisturedamage)[a]

New-onset physician-diagnosed asthma at age2065 years

4.7 (1.514.3)

Gunnbjrnsdttiret al

Prospective studywith a 7.9-yearfollow-up period(mean age at followup: 40 years)

Reported dampness (waterdamage, leakage, or moldgrowth) in the home[b]

New-onset asthma attack orcurrent use of asthmamedications[c]New-onset wheeze[c]New-onset nocturnaldyspnea[c]New-onset nocturnalcough[c]

1.1 (0.91.4)

1.3 (1.11.5)

1.3 (1.11.6)

1.3 (1.11.4)

Jaakkola et al Population-based

incident case-controlstudy (2163 yearsold)

Reported visible mold or

mold odor at work[c] and No wall-to-wall carpet atwork Wall-to-wall carpet at work

New-onset physician-

diagnosed asthma with bothreversible airwaysobstruction and a history ofat least one asthma-likesymptom

1.4 (0.92.1)

4.6 (1.119.4)

Children

Wickman et al Prospective study of Reported water damage, Three or more episodes of 1.7 (1.32.4)

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Reference Study design Environmental

exposure

Health outcome Odds ratio

(95% CI)

a birth cohort fromage 2 months to 2years of age

windowpane condensation,visible mold, or mold odorwhen child was 2 months of

age

wheezing after age 3months and either use ofinhaled steroids or

symptoms suggestive ofbronchial hyper-reactivity

Emenius et al Nested case-controlstudy of a birthcohort (2 years old)

One sign of dampness basedon home inspectionThree or more signs ofdampness based on homeinspection

Three or more episodes ofwheezing after age 3months and either use ofinhaled steroids orsymptoms suggestive ofbronchial hyper-reactivity

1.3 (0.82.2)

2.7 (1.35.4)

Pekkanen et al Population-basedincident case-controlstudy (17 years old)

Mold odor based on currenthome inspectionVisible mold based oncurrent home inspectionVisible mold in main livingarea based on current homeinspectionWater damage in main livingarea based on current homeinspection

New-onset physician-diagnosed asthma or newreferral to hospital after twoor more attacks of wheezing

4.1 (0.626.0)

1.2 (0.72.1)

2.6 (1.25.8)

2.2 (1.24.0)

a Present for 3 or more years and occurred at least 3 years before year of asthma diagnosis.

b Present any time in between the initial and follow-up survey.

c Present during the past year.

Table 3-2 -- Epidemiological studies investigating an association between indoordampness or mold and new-onset asthma that use incidence rate ratio as a measure of risk(Sahakian et al. 2008)

Reference Study design Environmental exposure Incidence rate

ratio (95% CI)

Adults

Cox-Ganser

et al

Cross-sectional study with

information on dates of hire andasthma diagnosis (mean age 46years)

Office building with water damage and

mold contamination based on buildinginspection

7.5 (no CI)

White et al Cross-sectional study withinformation on dates of hire andasthma diagnosis (mean age 48

School building with evidence of waterdamage and mold contamination based onbuilding inspection

8.5 (no CI)

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Reference Study design Environmental exposure Incidence rate

ratio (95% CI)

years)

Children

Jaakkola et al[a]

Population-based cohort study witha 6-year follow-up period (17 yearsold at baseline)

Reported mold odor in the home[b] 2.4 (1.15.6)

Reported visible mold in the home[b] 0.6 (0.21.7)

Reported moisture on surfaces in thehome[b]

0.9 (0.51.5)

Reported water damage in the home[b] 1.0 (0.42.3)

Any of above dampness indicators 1.0 (0.71.5)

a Cited in Fisk WJ, Lei-Gomez Q, Mendell MJ. Meta-analyses of the associations of respiratory health effectswith dampness and mold in homes. Indoor Air 2007;17:28496.

b Present during the past year at time of initial survey.

The results of these studies confirm a statistically valid association between dampness/moisture/ mould and asthma. This forms the basis for determining the extent and subsequent costof the mould in homes from damp environments using asthma statistics as relevant.

4. Cost Benefit Analysis for mould affected households and Health Care

The cost to society for failure to proactively address and reverse the impact of poor indoorenvironments requires measurement of effects. The major effects are: respiratory disease; allergyand asthma symptoms; sick building syndrome (SBS); and worker performance. The cost ofthese major effects on patients in society will culminate in a financial impact to society ( directlyin cost of health care and reduced economic output) that is measureable.

A few residential studies (Kercsmar 2006; HowdenChapman 2007; Fisk et al 2007, 2010)provide general costs to support a cost benefit analysis for residential ill-health solutions. Aswell, many studies look at the health affect of poor IEQ/IAQ in commercial buildings with some(Fisk 2005; Syal 2009; Cascadia 2009; Kosonen 2004) giving cost parameters based onproductivity gains which will be addressed in the next section. The assumptions used to compareto residential to commercial environmental results is duly noted.

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Table 4-1: Key Residential and population Research findings

Howden-Chapman 2007: 38% (1.3 % of population to 0.8%) reduction in hospital visits after homesremediated; 54% reduction in sick days from school and 39% reduction in lost work days in New Zealand.

Kercsmar (2006) 90% reduction in asthma impact after remediation of homes for at risk patients

PHAC 2007 key asthma facts:

Respiratory disease in Canada attributable to asthma (2005): 2,817,200

Hospitalization in Canada from asthma: 202,317*

Direct health care cost in Canada for asthma care (2000): y $705.4 mil

Indirect health care cost in Canada for asthma care (2000): y $840.0 mil

CDC 2002; episode of asthma attack y1999 USA population: 10,488,000

1999 annual # of doctor office visits due to asthma: 10,808,000

1999 annual # of emer room visits due to asthma: 1,997,000

1999 annual # of hospital stays for asthma: 478,000

The fraction of asthma attributable to workplace mould exposure is suggested to be 35.1% (Jaakkola 2002)

*. PHAC 2007 fig 5.6 & 5.7. Canada population by demographic 2004 CANSIM table051-0001

Determining the impact of mould affected homes on the health care system can bedetermined through the PHAC and CDC asthma statistics although the value of the impact willonly be on the smaller population of asthmatics. Another method would be to use the causalrelationship between damp homes and mould growth with cumulative statistical informationprovided by Howden-Chapmen (2007), Fisk (2010), and Dales (1991) and the number of homes

in Canada.

First well assess the impact based on asthma statistics alone.

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Jaakkola (2002) asserts that 35.1% of asthma can attributable to workplace moldexposure. This valuation is used comparatively to assess the impact of mould in asthma relatedresidential based environmental ill-health.

Further, Kercsmar (2006) identified the median cost to remediate a home for better IAQ tobe $3,500. Local research provides a range of $ 3,000 - $ 5,000 (2010) for moisture basedremediation of homes in the Okanagan. Kercsmar (2006) also identified that this remediationsaved 15 acute care visits (ACV)/ 11 homes or 1.4 ACV per affected person). An ACV canaverage 2 - 3 days in hospital.

Canadian statistics identifies asthma hospitalization rates to be approx. 280/100,000 ofpopulation for adults 25+ and 1,400 /100,000 for children 0-24 yrs. (PHAC 2007). StatisticsCanada sets the population of 0-24 yr to be 10,077,400 (2004) and 25+ 21,868,900 (2004) to befor a total of 202,317 hospitalizations due to asthma at 2004 population levels.

In the Okanagan at Kelowna General Hospital the emergency room/ outpatient visit (ERV)inter-provincial charge out rate is $238 (2010), a hospital per diem charge for medical standardward is $1,162 (2010) a night with critical care or intensive care per diem charge set at $ 2,949(2010). In addition is the obligatory supply of necessary drugs and puffers, and doctor time toaddress pre and post visits with these costs in the range of $ 500 - $ 1000 a year for theProvincial (MSA) portion. Using these rates and an average year to year ACV of 1.4 x 2.5overnights per visit and a standard ward charge of 1 night critical care and 1.5 nights standardward care plus one ERV and $500 for drugs per year including doctor visit charges provides a

cost of:

1.4*(2,949 + 1.5*1,162) + 238 + 500 = $ 7,447, say $ 7,500 per year per asthmatic

From this assessment, the health region is better off remediating the health affectedoccupants home once for $3,500 - $ 5,000, ( less than a 6 month payback on average) ratherthan continue to address the ill-health of that patient over the years they continue to reside in thathealth region. At the highest cost of remediation, the health region can save upwards of $145,000

per patient over a 20 year period.

Considering the 202,317 hospitalizations in Canada due to asthma (2004) using 35.1% as theasthma based health impact attributable to mould in built environments, and taking the cost ofcare value noted above, the health regions Canadian wide cost of care is a little over 532 milliondollars. This would remediate 106,520 mould infested home environments per year and reducethe impact on health care in the first year by $ 799 million dollars. The present worth of these

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values can be considered in reducing demand projections and thereby reducing the need forfuture built structures at a substantial savings to the Health Region.

To compare values, $ 1.545 billion a year is directly expended on direct and indirect health

care in Canada from asthma related sickness in Canada (PHAC 2007). If 35.1% is determined tobe from mould induced asthma, then the amount of $542 million dollars is saved in Canada byremoving mould from built environments. Given 2.3 million adult asthma sufferers at 35.1%,880,000 homes can be projected to be mould affected to the point of exacerbating asthma attackswhich would be addressed in 8.2 years.

Using the American CDC statistics noted below; 35.1% of 1.97 mil emergency room visits(ERV) and 35.1% of 478,000 hospital visits at 2.5 days each using the cost structure noted aboveis an approximate (conservative) burden of $3.1 billion dollars a year in the US health caresystem for treating mould affected asthmatics which can be eliminated with the pre-emptiveremediation of US homes with asthmatic occupants that are IAQ mould affected. At an upperaverage cost of $ 5000 to remediate a home, this can translate into the remediation of over600,000 homes a year.

A positive net present value of the measured reduction in future medical costs forms thebasis for a significant shift in how the medical system might address mould affected patients bychanging from reactive to taking proactive measures as the pressure to reduce health care dollarsmounts. Policy can be developed to ensure this shift occurs.

The second means to evaluate the overall cost impact of mould in homes on the health caresystem is to use statistically relevant information from site assessments conducted byresearchers.

Howden-Chapman (2007) found that by insulating homes in New Zealand, wherebyreducing heat loss and moisture development within the home, incidents of ill-health andcorrespondingly work sick leave and hospital visits dropped significantly. Hospital admissionsfor respiratory issues dropped 38% with the odds of respiratory symptoms (coughing/ wheezing/

colds and flu) cut in half after remediation of the home. Children in remediated homes had halfthe odds (54%) of having a day off school compared with the control group while adults had a39% reduction in lost work days due to respiratory symptoms. Low vitality is a trademarkresponse to SBS and mould affected environments. This study showed a drop in low vitalitycomplaints from 445 of 967 respondents (46%) to 290 of 967 (30%) respondents afterremediation of their homes, a 35% drop. Alternately, the happiness scale tipped upwards by49%.

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Kercsmar (2006) showed a significant reduction in symptom days and health care supportfor asthmatic children who lived in damp mould affected homes that were subsequentlyremediated of mould and moisture sources. Subsequent review of the post remediation portion ofthe study indicates that the rate of asthmatic impact was reduced from 33% of the remediationcontrol group to only 3.4%, a 90% reduction rate. The study connects damp environments tomould growth and to the significant increase in incidents of asthma and other respiratorysymptoms in our North American population. Symptoms are noted as disproportionately high inthe inner cities with ethnic minorities bearing the brunt of the impact.

These results compare to the research reviewed prior.

4.1 Moving towards a social cost / benefit valuation of the impact

A social cost benefit analysis is based on the criteria that every decision must be followedto its logical conclusion with all aspects of it valued and incorporated into the decision process toensure a full cycle approach is taken towards a fully sustainable solution. This includes ensuringall impacts are tallied, including hard costs; such as, emergency room visits and bed nights, drugsand doctor visits; soft costs, such as immobilization at mortality; and costs of externalities such

as; carbon footprint of renovations; disposal of contaminants, recycling of waste, and themeasure of human externalities such as the reduction or loss of well-being, mental health,productivity, and creativity, among others. It also includes reduction of ones station in life:

With the loss of a significant (income earning) family members health, there is a quickdownward spiral towards chronic financial and corresponding mental stress which David Shiplerdescribed as the tenuous state of existence of the working poor in his book, Working Poor:Invisible in America. "A rundown apartment can exacerbate a child's asthma, which leads to acall for an ambulance, which generates a medical bill that cannot be paid, which ruins a credit

record, which hikes the interest rate on an auto loan, which forces the purchase of an unreliableused car, which jeopardizes a mother's punctuality at work, which limits her promotions andearning capacity, which confines her to poor housing."

Interestingly, Shipler describes the externalities of ill-health although he was sharing theperspective of limited choice for those who are poor. But the fact remains, they are inexplicablyconnected. The cost in human potential is immense and difficult to measure. The tangible costs

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of the hospital and doctor visits and dispensation of drugs can start to form the basis for a costbenefit analysis and be conservative as the real cost includes that and more if one was to add theimpact on mental health with its corresponding burden on the health care system.

The key to a sustainable solution to poor IAQ in homes is a workable cost benefit anchoredhealth care model that verifies societal gains along with occupant health gains in the process ofridding homes of toxic mould (and otherwise poor IAQ).

5. Cost Benefit Analysis mould affected commercial properties

Studies pertaining to commercial office buildings indicate a significantly larger societalimpact by not addressing mould environments in built structures. These studies expose asignificant drop in productivity and increase in absenteeism that is due directly to SBS-likeconditions (Fisk 2005; Seppanen 2005) . Fisk identifies a global impact of 50 billion dollars(2005) to the American economy yearly. Some calculations indicate the cost of poor IAQ inbuildings exceeds the cost of heating those buildings (Seppanen 1999) and measures to improveIAQ in buildings are cost effective when health and productivity are included in the assessment(Djukanovic et al. 2002; Fisk 2000; Hansen 1997; Seppanen and Vuolle 2000; Tuomainen et al.2002). IOM 2000 connects asthma and allergies to indoor air allergens related to building factorssuch as ventilation and filtration, humidity, and dampness. Benefits of better IAQ include(Seppanen 2000): reduced medical care costs, reduced sick leave, higher productivity, lower

turnover, and lower cost of building maintenance due to reduced IAQ complaints.

Table 5-1: Key commercial research and population findings (USA)

Fisk 2000: 176 mil lost days/yr and 121 mil work days/yr of reduced activity

Fisk 2000: 15 bil/ yr cost of allergy and asthma

Fisk 2000: reduce sick leave by 9 20% by improving IAQ

Fisk 2000: Mendell et al. 2002 a 2% increase in productivity by improving IAQ

Howden-Chapman 2007: 39% reduction in lost work days due to respiratory symptoms when homesremediated.

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The measured expense to employers was reduced by $9,200 per employee per year (Geotzel 2001) forbetter indoor air quality with a direct health component of $4,700; turnover component of $3,700 and $800for reduced unscheduled absences.

CDC 2002; episode of asthma attack y1999 USA population: 10,488,000

1999 annual # of doctor office visits due to asthma: 10,808,000

1999 annual # of emer room visits due to asthma: 1,997,000

1999 annual # of hospital stays for asthma: 478,000

The fraction of asthma attributable to workplace mould exposure is suggested to be 35.1% (Jaakkola 2002)

A cost benefit assessment was conducted by Holcomb (1994) that indicates a cost savingsoverall when taking into account reduced absenteeism due to illness to a building of workers(600 700 daytime occupants) are in the range of $35,000 $70,000 per year (Holcomb, 1994)

or approx 70,000/700 = $100 per worker per year. The cost to upgrade the building is not noted;but studies show that upgrades can achieve up to a 40% rate of return on investment. Part of thatwould be in worker efficiency increase and absenteeism decrease; but overall, it appears that theemployer can benefit by upgrading their office space not only with a lower turnover and sickleave rate, they can also benefit financially by achieving a high rate of return on capitalinvestment from the productivity savings and increased revenues from healthier and happierworkers.

To further substantiate the financial benefits of increasing IAQ in buildings, the publication life cycle cost analysis of occupant well-being and productivity in LEED office by Syal et al.

(2009) is included from the literature review. This paper outlines the research conducted on twoLEEDS buildings, one silver and one platinum, in three major steps: one, determine theincremental first costs for the increased IEQ (indoor environment quality); two, then measure theincremental change in occupant well-being and productivity through survey; then three, establishthe life cycle cost benefits. The research results confirm significant life cycle cost benefits thatindicate LEED buildings can be economically viable investments. The report variables werelimited to the economic performance to occupant well-being and productivity and excluded theother IEQ elements included in LEED (energy; operations and maintenance; product lifecycles;employee turnover rates (which provide a positive net benefit per Geotzel (2001); liability relatescosts, etc).

Reviewing LEED buildings for ramifications towards instituting capital expenditures toproactively deal with health care cost outlay is not a direct connection to poor IAQ in homes,although similarities are consistent. Similar building products and techniques are used inconstruction. The heating, ventilation, and filtration systems are far more superior in commercialbuildings, leading to conservative results when applied to residential environments. Residentialenvironments have far higher probability for dampness that causes mould due to more extreme

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living environments, questionable hygiene, and lower levels of housekeeping expected incommercial buildings. Further, the costs to construct and remediate commercial buildings aremore than double that of typical residences due in part to higher quality products and systemsrequired. The LEED research results therefore are expected to be conservative when compared toresidential environment.

The research results from Syal (2009) are significant in that the benefits far outweighed theinitial outlay costs. Whereby incremental capital costs were determined to be a 2 2.5% savings,similar to many studies researched (Kats (2003), Stegall (2004), Langdon ( 2004, 2007), in reducedabsenteeism for asthma/ respiratory allergies/ depression/ stress and higher productivity of over2% totalled to a little over $ 1,000 per affected person per year (97% of which was measuredfrom productivity gains). One building had a total population of 56, another building had 207. Ofthe total population, approx. 18 35% were measurably occupants who has a history of asthma,stress, and depression. The total annual economic benefits measured at $ 69,601 and $250,694respectively per building. By assuming the registered gains are equally distributed over the entire

population of the two buildings, the savings per worker is approx. $ 1,200 or using the upper endof occupant history with asthma (35 %), $ 3,400 per affected worker. Further by dissecting theresults down to the mould affected using Jaakkolas 35.1% effects ratio, the mould affectedcauses an impact of $3,400 x .351 or almost $ 1,200 to the economy per year when affectedcommercial environments are not remediated.

Further, the life cycle cost analysis for the two buildings was conducted using a benefit costanalysis with a study period of 25 yrs; an inflation rate of of 3%; and a discount rate of 6%.These values remain relevant for 2010. The smaller building provided a B/C of 31 whichdropped to 21 for a SP of 15 years and rose to 44 with an IR increase to 6% from 3%. For thebase scenario, the investment had a 7 month payback period with a rate of return of 167%. Thelarger building provided a B/C of 10 which decreased to 7 for a 15 year SP and increased to 14for an IR of 6%. For the base scenario, the investment had a 2 year payback period with a rate ofreturn of 50%. Other LCCA studies provided a wide range of ratios ( 15-16 Kats (2003), 1-2SBW (2003), 1.7 Ries et al (2006), and 1 Romm and Browning(1994)).

These results indicate a significant value in undertaking a proactive reduction in mouldaffected commercial environments is attainable.

6. Concluding Remarks and recommended future initiatives

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Unimpeded, ill-health environments due to toxic moulds are found to translate into asignificant financial as well as social impact on society, in the form of a critical load on thehealth care system an increased impact on family and the overall social fabric of society and lossof productivity in the workplace as well as an overall adverse impact on business conditions inNorth America. These impacts are of crisis proportions with an upward trend and might well be

the cancer of future generations.

The residential toxic mould burden on North America health care systems alone is calculatedto be $3.6 billion dollars a year. The net cost benefit to the health care system alone for removingtoxic moulds from homes has been calculated to be in excess of $ 145,000 per affected personover their lifetime (based on a 20 year period). The real cost to society is in the hundreds ofbillions of dollars per year when the issue is expanded to include commercial, financial, andsocial based impacts. This paper recommends further investigation into solutions to correct thissocietal level crisis are critical to the well-being of families, community, and the North Americaneconomy at large.

Corrective efforts have long been recommended. Pilot projects and limited specific healthstudies conclude that better indoor environments translate to increased well-being, lowerincidents of ill-health, and higher productivity in the workplace concluding in fewer doctor andemergency room visits and reduced hospital stays. Reducing dampness and mold in buildingswould reduce the occurrence of respiratory infections take corrective actions where suchproblems occur (Fisk 2010) should be a rallying cry to enact the IAQ cost benefit model torealize significant social and personal benefits in the near term.

This report concludes there is sufficient evidence of an association between damp indoorenvironments or mould and asthma-like symptoms exists with specific fungi (mould) associatedwith the development of asthma and asthma-like symptoms. Concurrently, there is evidence thatremediation reduces respiratory health effects.

To date, concrete initiatives to increase the indoor environmental quality of our housingstock have been limited and inconsequential. Canadian Health Authorities are not tracking healthcomplaints pertaining to IAQ toxic mould issues that emanate from housing and as such are notconversant with the critical impact this is having on emergency room visits and hospital bedstays. Further and specifically, the BC Residential Tenancy ombudsman and its office are nottaking IAQ mould issues in rental homes seriously as repetitive complaints by mould affectedtenants go unattended. There is a significant disjoint between the affected population and societalcare and attention.

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The focus of this paper exposes the impact of this disconnect and provides a cost-benefitapproach (model) to proactively address the problem of ill-health in homes due to toxic mouldenvironments. The cost-benefit to remedy damp environments against mould growth is measuredagainst the financial impact to society of an overloaded health care system by delaying remedy.Our preliminary figures indicate a conservative 6 month payback using a sound financial based

cost-benefit business model that mobilizes the local Health Regions through the Ministry ofHealth to undertake proactive remediation programs in homes that are known to be the source oftoxic mould that aggravates occupants who then seek health care solutions. By enacting thismodel, the participating Health Authorities not only become an integral part of a sustainablesolution to ill-health due to mould ingestion, they reduce its effects on the cost of health carewith a significant net financial benefit.

The real cost of not addressing toxic mould in homes must include externalities such asgeneral loss of well-being, increased mental health issues, the increased emotional impact on selfand family, as well as the ever rising financial cost to society for increased health care and

municipal infrastructure requirements is even higher. As far back as 2004, the association between excessive indoor dampness and respiratory problems has been made withrecommendations that changes in built structure design and maintenance be undertaken through abroad range of public health initiatives (IOM, 2004).

These research report findings lead to the end expectation of the development of a corporate/municipal/ social mission to rid homes of adverse IAQ environments before toxicity significantlyaffects the function of occupants that is both practical and sustainable. Add in the impacts onbusiness productivity; lost work days; development of mental health issues from chronic pain;literally hundreds of billions of dollars, can be recaptured and lives rebuilt from this simplemission.

Acknowledgements

We would like to acknowledge the University of British Columbia graduate program for its supportand research recommendations. The Government of Alberta Health Services department and InteriorHealth of the Okanagan region were very helpful in directing inquiries to the proper offices for statisticsconsidered for this paper.

Limitations

A thorough review of literature found the scientific extension of the subject matter sparseand somewhat limited. Motivation for research came from personal experience in the IAQ

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residential field over the past 8 years that exposed a lack of science based facts and limitedresearch. The literature search as well as personal experience in the form of networking and professional communication provided the basis for determining the present IAQ residentialconditions and issues.

Economic results as well as medical based results are also drawn from commercialbuilding and multi-family environments and inner-city studies with study results assumed to beconsistent with single family dwelling environments. Further study is necessary to prove theaccuracy of this assumption.

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Figure and Table Legend

Table 2-1: Supporting literature review studies and research

Table 3-1: Epidemiologic studies investigating an association between indoor dampness ormold and new-onset asthma or new-onset asthma-like symptoms that use odds ratios as ameasure of risk

Table 3-2: Epidemiological studies investigating an association between indoor dampness ormold and new-onset asthma that use incidence rate ratio as a measure of risk

Table 5-1: Key Commercial Research findings (USA)

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