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Energy Efficient Homes: A Heaven for Respiratory Illnesses


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The built environment has changed dramatically due to the increased interest in mitigating climate change. Homes are becoming more energy-efficient, responding to energy issues, and reducing carbon emissions primarily. Nevertheless, we started to realize the unintended consequences of these changes that impact a home's indoor environment and occupants' health. Indoor air quality is a critical aspect as indoor pollutants are increasing in homes. More than ever, it is crucial to adhere to the best ventilation practices, building materials, and cleaning products. Additionally, behaviour changes, such as those for healthy homes, can prevent their health impact. Interdisciplinary research between public health and building professionals needs to educate citizens and present evidence for legislative changes and recommendations to spur change to reduce indoor air pollution and protect vulnerable populations preventing harmful effects on future generations' health.
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Chapter 3
DOI: 10.4018/978-1-7998-7023-4.ch003
The built environment has changed dramatically due to the increased interest in mitigating climate
change. Homes are becoming more energy-efficient, responding to energy issues, and reducing carbon
emissions primarily. Nevertheless, we started to realize the unintended consequences of these changes
that impact a home’s indoor environment and occupants’ health. Indoor air quality is a critical aspect as
indoor pollutants are increasing in homes. More than ever, it is crucial to adhere to the best ventilation
practices, building materials, and cleaning products. Additionally, behaviour changes, such as those
for healthy homes, can prevent their health impact. Interdisciplinary research between public health
and building professionals needs to educate citizens and present evidence for legislative changes and
recommendations to spur change to reduce indoor air pollution and protect vulnerable populations
preventing harmful effects on future generations’ health.
This chapter considers the impact of sustainable architectural design in the indoor environment and hu-
man health by looking at the built environment’s energy-efficiency evolution, which has changed mainly
due to climate change concerns. As homes have become more energy-efficient, unintended consequences
such as poor indoor air quality and respiratory illness arise. This chapter discusses these issues within
residential indoor environments, emphasizing indoor air quality (IAQ), possible health outcomes, and
prevention considerations.
Energy-Efcient Homes:
A Heaven for Respiratory Illnesses
Alejandro Moreno-Rangel
Lancaster University, UK
Genny Carrillo
Texas A&M University, USA
Energy-Ecient Homes
Issues, Controversies, Problems
The world’s overgrowth has created challenges for many countries to have enough space to build houses,
to design and develop energy-efficient homes, and reduce the cost to operate them compared to existing
households. The new “energy smart” houses are 40-60% more efficient than older homes (Coopera-
tive Energy Futures, no date). They are designed with an improved Mechanical Ventilation with Heat
Recovery (MVHR) system, high-performance windows, no air filtration, and water efficiency. It is
acknowledged that energy-efficient homes offer great comfort due to the combination of temperature,
humidity, and air movement (Schieweck et al., 2018). Part of the efficient promise is their resale value
due to its high-performance standard and low utility costs. Many people are primarily interested in the
body of evidence about climate change and how an energy-smart house can decrease our need for energy,
water and improve our world. Nonetheless, indoor environment problems (i.e., poor indoor air quality
and overheating) may arise when these aspects are not adequately addressed, causing health problems
(Davies and Harvey, 2008).
The energy-efficient homes need to use non-toxic materials in construction to improve indoor air
quality, which can reduce the rate of respiratory illnesses such as asthma (Institute of Medicine, 2000).
The materials and products used need to be emission-free and have very little or no VOC (Volatile or-
ganic compound) content. They also need to be moisture-resistant to prevent mould spores from growing
inside the house. Indoor air quality (IAQ) can improve through ventilation and materials in the house’s
construction that controls humidity and allow a building to breathe (Crump, Dengel and Swainson,
2009). The house needs to be maintained responsibly, and owners need to keep up to date with changing
standards and policies related to energy-efficient homes.
This chapter has the following objectives (a) to review the changes for energy-efficient dwellings
and their impact on the indoor environment, (b) to describe the most common indoor air pollutants
problems and their implications to human health, (c) to present some considerations for prevention and
(d) to discuss healthy homes practices.
Climate Change and the Built Environment
The influence of climate change is one of the most pressing matters of our time (Mcnutt, 2013). Perhaps,
it is the most significant global impact caused by human activities (Treut et al., 2007). Humans are pol-
luting the Earth to a no-return point on which the natural systems cannot remain stable. In addition, the
rate of the use of non-renewable resources has surpassed historic peaks to the end of jeopardizing the
destabilization of Earth’s carbon cycle, creating new risks, and amplifying existing ones to natural and
human systems (IPCC, 2014).
The deterioration of the Earth’s carbon cycle affects how natural carbon sinks absorb CO2 from the
atmosphere, causing an increase of 2°C of the planet’s mean surface temperature (Schellnhuber et al.,
2006), unlikely to be avoided by the end of this century. In fact, between 1950 and 2010, greenhouse gas
emissions have caused an increase of 0.6-0.7°C (IPCC, 2014, p. 48). The International Panel of Climate
Change’s (IPCC) fifth report (IPCC, 2013, p. 4) notes:
Energy-Ecient Homes
“Warming of the climate system is unequivocal, and since the 1950s, many of the observed changes are
unprecedented over decades to millennia. The atmosphere and the ocean have warmed, the amounts of
snow and ice have diminished, sea levels have risen, and the concentrations of greenhouse gases have
According to the IPCC (2014) report, the Earth’s surface temperature is projected to rise between
0.3°C to 5.4°C over all the projected scenarios by 2100 (Figure 1). They also state that heatwaves are
very likely to occur more often and last longer. Extreme precipitation will become more intense and
frequent, and oceans will continue to warm and acidify, and sea levels will continue to rise. Likewise,
these effects are also exacerbated by air pollution. Climate change, air pollution, and human health are
related (Fairweather, Hertig, and Traidl-Hoffmann, 2020) see Figure 2, particularly asthma and allergies.
Air pollution and global warming are caused primarily by the combustion of gas, solid or liquid fuels
during energy production and use. One of the problems from green gas emissions (i.e., nitrogen oxides,
ozone) is the chemistry interactions from these air pollutants. The tropospheric ozone interacts with other
gases such as CO2 and NO2. Furthermore, climate change impacts the tropospheric and stratospheric
layers (Ramanathan and Feng, 2009).
As emphasized by Hopfe & McLeod (2015, p.3), “society faces rising energy prices, increased re-
source competition, and a moral imperative to create a sustainable built environment.” Clean growth,
the sensible use of resources, as well as an increased emphasis on a reduction in energy consumption,
sustainability, and resilience should move upfront on the agenda.
Drivers to Change the Way We Build
Building construction has evolved in recent years, particularly concerning housing. Environmental con-
cerns, high energy costs, and an increasing demand for housing have stimulated the transition towards
energy-efficient homes (Sadineni, Madala, and Boehm, 2011). However, these approaches primarily
focus on energy consumption and carbon emissions (Anderson, Wulfhorst, and Lang, 2015), and other
aspects, such as health and IAQ, had been left aside. The built environment is accountable for 40% of
the global annual energy consumption (Liu, Zhao, and Tang, 2010). On their own, buildings should
provide adequate indoor environmental conditions for human activities. Indoor comfort performs a vital
role in building energy consumption, as cooling and heating may account for 60-70% (Pérez-Lombard,
Ortiz and Pout, 2008).
A crucial concern, however, is that carbon emissions from the built environment are growing. The
Paris Agreement and the Kyoto Protocol seek to mitigate climate change by reducing greenhouse emis-
sions. In a way, they denote the first steps towards sustainable buildings. It is estimated that residential
carbon emissions related to energy consumption increased at an annual rate of 1.7% between 1971 and
2004 (IPCC, 2007). In the European Union, buildings are responsible for around 40% of the total carbon
emissions (Petersdorff, Boermans, and Harnisch, 2006), while in the U.K., residential carbon emissions
stand at about 15% (BEIS, 2019) and 19% in the USA (EPA, 2018).
The housing demand will continue to grow in the forthcoming years, as developed regions extend—and
so will related carbon emissions and energy demands. Energy-efficient homes typically use mechani-
cal ventilation systems (Sharpe et al., 2016), higher levels of airtightness, better insulation (Feist et al.,
2005), and reduced ventilation rates (Dimitroulopoulou, 2012) to lower their energy demands, and in
Energy-Ecient Homes
doing so, the related long-term carbon emissions. Ventilation is a critical aspect that impacts thermal
comfort, indoor air quality (microbial and chemical), and moisture-related allergens in homes.
Implementing a wide range of passive or active energy-efficient methodologies can help enhance
energy efficiency in homes. Active methods include a range of improvements that require energy to
function, such as MVHR, heating, energy-efficient electric bulbs, white goods, and other appliances.
Passive technologies rely on or make the best use of natural resources, such as solar power for light-
ing and heating, daylight, natural ventilation, or thermal mass. As interest in energy-efficient homes is
growing, new approaches to low-energy buildings, such as Passivhaus, LEED, BREEAM, have been
developed. The construction process is explained in Figure 3.
Figure 1. Time series of global climate changes, risks, and impacts (2006-2100).
Source: (IPCC, 2014)
Energy-Ecient Homes
Governments have set targets for low-energy buildings to encourage the transition to energy-efficient
buildings and reduce carbon emissions. For instance, the Energy Performance in Buildings Directive,
established in 2010, requires all new European buildings to be near ZEB by 2020 (CEC, 2010). Some
states in the USA, such as California, established similar goals for near ZEB dwellings by 2020 (CEC,
2007). The U.K. government agreed to achieve zero carbon homes by 2016 as semi-detached, detached,
and end of terrace homes 46kWh/m2, while new mid-terraced houses and apartments aimed to achieve
39kWh/m2 for heating and cooling demands. Nevertheless, this proposal ended in 2015 (Ares, 2016),
following the governments’ announcement to stop the Allowable Solutions Carbon Offsetting Scheme
and ‘keep energy efficiency standards under review’ (H.M. Treasury, 2015, p. 46). The critical barriers
for its implementation were the increased capital cost, public awareness, scheme viability, and knowledge
of occupants (Heffernan et al., 2016).
Figure 2. Air pollution trends between 1990–2040. Source: (Amann et al., 2020)
Energy-Ecient Homes
Energy-Efficient Buildings
With the interest of reducing energy consumption and lowering carbon emissions, new approaches to
building design have reduced energy demands and improved indoor environmental conditions by reduc-
ing heat losses with passive and active methods. Existing building components and energy systems have
improved drastically since the 1970s. Some innovative buildings achieved extraordinary heat demand
reductions; nevertheless, the additional costs were so high that they could not be repaid by saving fuel
costs (Feist et al., 2005). We are transitioning from traditional building practices to ZEB. Such a transi-
tion has been possible through different approaches to building design and construction to meet low-
energy demands. Nevertheless, most of this transition has been driven by energy and carbon emissions
concerns, while others, such as health, were left aside.
The current transition to near Zero-Energy Buildings has been made possible through different building
design approaches for energy demands. Such buildings provide a proven record for low/ultra-low-energy;
besides, they are also economical, resource-efficient, and provide high occupant comfort and resilience
to future climate changes (Hopfe and McLeod, 2015). Hence, different organizations formulated rating
systems to promote low-energy-low-carbon building design and construction; and recognize and quantify
such achievements through certification. Internationally recognized systems include BREEAM (Build-
ing Research Establishment Environmental Assessment Methodology), LEED (Leadership in Energy &
Environmental Design), Living Building Challenge, and Passivhaus Standard, among others. However,
adopting a standard or regulation does not guarantee the desired effects, as buildings still display per-
formance gaps (Miguez et al., 2006), such as poor indoor air quality (IAQ) and energy.
Some studies suggest that Belgian (Hens, Parijs and Deurinck, 2010), French (Cayre et al., 2011), and
British (Kelly, 2011) low-energy homes may consume more energy than expected. The common causes
Figure 3. Energy-efficient construction process. Source: (Bere, 2013)
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were related to occupant behaviour and indoor environment comfort—such as lighting use, window
opening, heating expectations (Masoso and Grobler, 2010)—as the main determinants (Santin, Itard
and Visscher, 2009; Gram-hanssen, 2010). For instance, the UK Standard Assessment Procedure (SAP)
for new dwellings and reduced SAP (RdSAP) do not assess energy efficiency. Instead, they calculate
the performance effectiveness and the additional carbon emissions (Kelly, Crawford-brown and Pol-
litt, 2012), which may provide misleading estimations. Most discussions on energy-efficient buildings
include energy, materials, site impacts, water use, and indoor environmental quality, and IAQ, which
merits urgent attention (Persily, 2014). As the building envelope becomes more and more airtight to
minimize thermal—and energy—losses, we start realizing the unintended consequences to the indoor
environment and our health.
Air pollution is a mix of hazardous substances from human-made and natural sources (National Institute
of Environmental Health Sciences, 2020). Particles and aerosols produced from the combustion process
comprise air pollution, and they come from vehicle emissions, burning wood, coal, oil, other fossil fuels,
and manufacturing processes. Children, the elderly, and pregnant women are at higher risk of exposure
if living in urban areas where they contact smog and microscopic particles. The Clean Air Act of 1970,
created in the United States, required the Environmental Protection Agency (EPA) to set National Ambient
Air Quality Standards for pollutants considered harmful to public health and the environment. Air quality
standards are established for six common air pollutants known as “criteria pollutants” (United States,
2011): carbon monoxide, lead, nitrogen oxides, ground-level ozone, particle matter, and sulfur dioxides.
We are exposed to both indoor and outdoor pollution throughout our lives. However, studies have
shown that health risks from exposure to indoor air pollution are higher than outdoor air pollution (United
States Environmental Protection Agency, 2020). A mixture of pollutants from indoor (i.e., smoking,
cooking, and airborne suspended particles) and outdoor activities (i.e., vehicular traffic and industrial),
as well as the building-related factors (ventilation and gas emissions from building materials), influence
IAQ (United States Environmental Protection Agency, 2020).
Thermal Comfort
Thermal comfort is an essential parameter in dwellings. It may be the one that we are more aware of and
have the highest degree of control, hence impacting overall energy consumption. Although temperature,
and relative humidity, to an extent, are not pollutants, they also have an exacerbating impact on indoor
material emission rates (Haghighat and De Bellis, 1998), perceptions of IAQ (Fang, Clausen, and Fanger,
1998), and health in terms temperature extremes (Neill and Ebi, 2009).
Studies have established that comfort diminishes at high temperatures, causing sleep disturbance,
reduced productivity, diminished attentiveness, and impaired judgment (Peacock, Jenkins, and Kane,
2010). Exposure to high temperatures increase has several impacts on health. It increases the risk of heart
stroke (Bouchama and Knochel, 2002), respiratory and cardiovascular illnesses (Anderson et al., 2013).
Energy-Ecient Homes
Heat-related effects can occur relatively soon after exposure. As such, it is essential to address overheating
in homes. Overheating problems in energy-efficient dwellings have been measured (McGill et al., 2016)
and contextualized with IAQ measurements (McGill et al., 2015). One of the most accepted definitions of
overheating is “the phenomenon of excessive or prolonged high temperatures in the home, resulting from
internal or external heat gains, which may have adverse effects on the comfort, health or productivity
of the occupants” (Zero Carbon Hub, 2015, p. 11). Different criteria are utilized to evaluate the risk of
overheating, either through static or dynamic criteria. However, there is no universal characterization of
overheating conditions, and neither a standard for the domestic sector (Zero Carbon Hub, 2012, 2015).
Thermal comfort is not just a function of high temperature, as other factors are involved (Nicol, 2004),
particularly in buildings without mechanical cooling (Nicol and Humphreys, 2002). Relative humidity
also impacts thermal comfort. Relative humidity depends on temperature, as air at higher temperatures
can hold higher levels of water vapour. When assessing the indoor environment, psychrometric charts
provide information about the air’s behaviour, revealing the relation between temperature, relative humid-
ity, and moisture content, helping to define a comfort area. Relative humidity can also support identifying
the risk of dampness, mould growth, and the proliferation of house dust mites and other invertebrates.
Indoor Air Quality
Several definitions of “acceptable/healthy IAQ” have been suggested over the years, reflecting the evo-
lution of indoor air understanding. In the past, healthy IAQ was associated with outdoor air, building
design, and indoor pollution control (WHO, 1991). It was thought that clean outdoor air guaranteed a
healthy indoor air environment and that human bio-effluents were the major indoor pollutants (Mølhave
et al., 1997). Although these assumptions might still be relevant today, we now understand that the air
quality is far more complicated than these aspects.
The number of air pollution sources and airborne contaminants found indoors is considerable; none-
theless, a few of them have been characterized (Katsouyanni et al., 2004). For instance, over 900 pollut-
ants, biological materials, and ultrafine particles associated with building materials (SCHER, 2007) are
present in the air. Porteous et al. (2014) suggest that occupant activities such as passive indoor drying
can influence IAQ as moisture levels may boost dust airborne mould spores and mite populations. Jacobs
(2007, p.p. 977) defined indoor air pollution as “chemical, physical or biological contaminants in the
breathable air inside a habitable structure […]” with the potential to detriment the well-being of its oc-
cupants. Consequently, an IAQ definition should consider health and comfort aspects as Rosseau (2001,
p.p. A-3) suggests: an acceptable IAQ should have “absence of air contaminants which may impair the
comfort on the health of building occupants.” Rosseau recognizes that air free from all contaminants is
challenging to achieve. Nevertheless, it should be understood as the absence of pollutants that can affect
typical occupants’ health.” The American Society of Heating, Refrigeration, and Air-cooling Engineers
(ASHRAE 2007, p.3) defines acceptable IAQ for high-occupancy buildings:
“air in which there are no known contaminants at harmful concentrations as determined by cognizant
authorities and with a substantial majority (80% or more) of the people exposed do not express dis-
Energy-Ecient Homes
As homes adopted more significant requirements of airtightness, ventilation, and insulation to reduce
energy consumption through heat losses, the outdoor-indoor air exchange decreased. In addition, the
increased use of chemicals and synthetic building materials caused high concentrations of chemical
off-gassing, such as VOCs, on top of human bio-effluents (Zhang and Smith, 2003). Perhaps the most
efficient way to control and reduce indoor air pollution is to limit its sources (Fanger, 2006). Sundel
(2014) advocates that building factors that may influence IAQ are ventilation, dampness, building ma-
terials, and indoor air chemistry. However, we ‘know’ that building characteristics such as ‘dampness’
a low ventilation rate and certain building (furnishing) materials are, but we do not know how, or why
(Sundell, 2004, p. 57).
Sources of Indoor Air Pollution
The sources of indoor air pollutants in buildings are varied. Nevertheless, we can characterize the air
pollutants as they include allergens, combustion products, tobacco smoke, volatile organic compounds
(VOCs), as well as gases from building materials, furnishing, cleaning, and personal care products (Ja-
cobs, Kelly and Sobolewski, 2007). Biological particles (bacteria, fungi, pollen, and cockroach allergens)
have been linked with asthma or its exacerbation (Do, 2016). A summary of sources and emissions is
provided in Table 1 and Figure 4. Although sources play a vital role, the actual concentration of the
pollutants also depends on other factors. According to Maroni et al. (1995), they are:
the volume of air contained indoors
the rate of production or release of the pollutant
the rate of removal of the pollutant
the rate of exchange with the outside atmosphere
outdoor pollutant concentration.
The most common indoor air pollutants are:
Carbon dioxide (CO2) levels are associated with human-related pollution, but they may be disas-
sociated from other pollution sources, such as off-gassing from building materials and furniture. Levels
of CO2 are frequently used as indicators of ventilation (Porteous, 2011) and IAQ (Curwell, March
and Venables, 1990). Levels below 1,000 ppm are considered adequate for these purposes (Porteous,
2011) as human bio-effluents were considered the major indoor air pollutant (Mølhave et al., 1997).
Wargocki (2016, p. 114) states that ventilation rate in homes is associated with health in particular
with asthma, allergy, airway obstruction, and SBS symptoms […] ventilation rates above 0.4h-1 or CO2
below 900ppm in homes seem to protect against health risk.” Nevertheless, CO2 itself is not an indoor
air pollutant (Satish et al., 2012) despite adverse effects on human well-being and productivity (Kajtar
et al., 2006). CO2 is influenced by several parameters, such as its disposal, building openings, and heat
(Steiger, Hellwing, and Junker, 2008). Therefore, a more prudent practise is to use CO2 as a metric of
outdoor air ventilation (Sundell et al., 2011).
Indoor CO2 concentrations above 700 ppm of the outdoor level are deemed acceptable (ASHRAE,
2007), but this is founded on the assumption that outdoor CO2 levels are adequate (typically 300-500ppm).
Mechanical ventilation is crucial to meet this target, particularly in energy-efficient homes with high
airtightness levels (SCHER, 2007). The EN 13779:2007 categorizes the IAQ in occupied zones based
Energy-Ecient Homes
on four IDA categories dependent on the CO2 levels above the outdoor air with recommended outdoor
air flows (Table 2). Normal outdoor CO2 levels can reach 400ppm, although, in city centres, 500ppm is
a more realistic assumption (CIBSE et al., 2015). Using the IDA 2 values and 500ppm as the outdoor
baseline would result in CO2 levels between 900-1,100ppm (1,000ppm default value) for indoor spaces.
Table 1. Sources and emissions of air pollution.
Sources Emission
Building materials and elements
Fire retardants Asbestos
Insulation Asbestos, formaldehyde
Boilers Carbon monoxide
Stoves Carbon monoxide
Gas or kerosene heaters Carbon monoxide
Particleboard and plywood Formaldehyde
Furnishing Formaldehyde
Air conditioning systems Micro-organisms
Adhesives and solvents Volatile organic compounds
Paint Volatile organic compounds
Building materials (concrete, stone) Volatile organic compounds, radon
Internal surfaces Fungal spores
Human-related (activities and occupants)
Respiration Carbon dioxide
Combustion (cooking, fireplace) Carbon dioxide, volatile organic compounds, particulates.
Fuel-burning Carbon monoxide, nitrogen dioxide, polycyclic aromatic hydrocarbons, sulphur
Tobacco smoke Carbon monoxide, volatile organic compounds, particulates, polycyclic aromatic
People Micro-organisms
House Dust Allergens
Domestic animals Allergens, micro-organisms
Cleaning products Volatile organic compounds
Motor vehicles (in garages) Carbon dioxide, nitrogen dioxide
Outdoor air Biological particles, benzene, nitrogen dioxide, particulates, pollens, sulphur dioxide
Trees, grass, weeds, and plants Pollens, fungal spores
Soil Radon, fungal spores
Adapted from Crump et al. (2009) and Spengler and Sexton (1987)
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Particulate matter 2.5µm (PM2.5) refers to ultrafine particles or droplets that are 2.5µm or less in
diameter. Their composition fluctuates, but it comprises dust, smoke, soot (AQEG, 2012), mineral ashes
(i.e., calcium carbonate, chlorides, coal, metal oxides, mould spores, oil ash, pollen, sodium), other air-
borne matter (i.e., fleece, fur, hair, vegetable fibres, such as cotton, flax, and hemp), silicate materials
(i.e., sepiolite clays, zeolites), and textile fibres (i.e., asbestos, glass and ceramic, nylon, polypropylene,
silicates, Crump et al., 2002). The impact of airborne particulate matter on human health is linked di-
rectly to the size of the particles (Harrison et al., 2010). Continuous exposure to PM2.5 may impair health
as respiratory disease outcomes correlate to PM2.5 exposure and concentrations (Harrison et al., 2010).
As concern for PM2.5 effects on human health increases, particularly in residential buildings (Crump,
Dengel, and Swainson, 2009), several exposure thresholds have been set. For instance, Laxen et al.
(2010) suggest that there is no safe level for short- or long-term exposure. Other thresholds set daily
average exposure between 8µg/m3 (National Environmental Protection Council, 2003) and 25µg/m3
(Commission, 2015). Nonetheless, it is generally accepted that levels above 25µg/m3 detriment human
health (WHO, 2000).
Figure 4. Sources of indoor air pollution. Source: (Holgate et al., 2020).
Table 2. IDA categories based on the EN 13779:2007
Category CO2 levels above outdoor air
(ppm) Rate of outdoor air per person (m3/h)
Non-smoking areas Smoking areas
Typical range Default
IDA 1 (high IAQ) £400 350 >54 72 >108 144
IDA 2 (medium IAQ) 400-600 500 36-54 45 72-108 95
IDA 3 (moderate IAQ) 600-1,000 800 21.6-36 28.8 43.2-72 57.6
IDA 4 (low IAQ) >1,000 1,200 <21.6 18 <43.2 36
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Total Volatile Organic Compounds (tVOC) are a large, diverse, and ubiquitous group of compounds
that vaporize at room temperature. The indoor Volatile Organic Compounds (VOC) mixture is often
known as tVOC. In the past, VOCs were difficult to study individually as human health hazards. Still,
their impact on health was investigated as a mixture (WHO, 1997), looking at associations between health
and temporal exposition of tVOC and their severity (Molhave, 1991). Nowadays, individual VOCs, such
as formaldehyde and benzene, are linked with significant health risks (WHO, 2010), and thresholds are
set for specific VOC instead of tVOC (Teichman and Howard-reed, 2016).
The World Health Organization (WHO) published guidance for safe exposure to individual VOCs
(see (WHO, 2000, 2010), and for a detailed list of individual VOC exposure limits, see CIBSE (2011)
and Health and Safety Executive (2011)). There are various thresholds for tVOC concentrations in non-
industrial environments, from 25µg/m3 (Berglund et al., 1997) up to 500µg/m3 (Delia, 2012). Neverthe-
less, 300µg/m3 over 8 hours is generally accepted as a maximum level (ECA, 1992).
TVOC concentrations are typically higher in new buildings, as they emanate from construction
materials and building contents (Brown et al., 1994). Indoor VOCs are released from various build-
ing materials (carpets, coving, linoleum, particleboard, power cables, and vinyl tiles) and construction
consumer products (adhesives, caulks, cleaners, paint strippers, paint thinners, and paints). They are
also related to human activities (deodorizers, dry-cleaned clothing, frying food, moulds, personal care
products, pesticides, showering, and smoking (Zhang and Smith, 2003).
Outdoor Air Pollution and Health.
Air pollution is a mix of hazardous substances from human-made and natural sources (National Institute
of Environmental Health Sciences, 2020). Particles and aerosols produced from the combustion process
comprise air pollution. They come from vehicle emissions, burning wood, coal, oil, other fossil fuels,
and manufacturing processes. Children, the elderly, and pregnant women are at higher risk of exposure
if living in urban areas where they contact smog and microscopic particles. The Clean Air Act of 1970,
created in the United States, required the Environmental Protection Agency (EPA) to set National Ambi-
ent Air Quality Standards for pollutants considered harmful to public health and the environment. Air
quality standards are established for six common air pollutants known as “criteria pollutants” (United
States, 2011). Those are carbon monoxide, lead, nitrogen oxides, ground-level ozone, particle matter,
and sulphur dioxides. They can be found in urban and non-urban settings and affected by geography,
season, and weather conditions. Particulate matters (PM) are believed to play a primary role in air
pollution’s systemic health effects. PM is classified according to its aerodynamic diameter. Particle
size is of utmost importance since respirable particles of less than 2.5 µm (particulate matter or PM2.5)
can penetrate deep into the lungs and cause damage (Xing, 2016). The chemical composition of these
particles varies based on source and secondary atmospheric reactions. Metals and polycyclic aromatic
hydrocarbons (PAHs), a large class of fused aromatic rings, are found adsorbed to these small particles.
Many individual PAHs present in complex mixtures are mutagenic and carcinogenic to humans. Air
pollution affects human health in diverse manners– one-third of deaths are due to stroke, lung cancer,
and heart disease. Manisalidis (2020) has shown that air pollution is considered the major environmental
Energy-Ecient Homes
risk factor in incidences of asthma, lung cancer, ventricular hypertrophy, Alzheimer’s and Parkinson’s
diseases, psychological complications, autism, and low birth weight.
Indoor Air Pollution and Health
Indoor and outdoor pollution contributes to the exposure we face in our lives. Biological particles
(bacteria, fungi, pollen, and cockroach allergens) have been linked with asthma or its exacerbation (Do,
2016). Among chemicals changing IAQ are carbon monoxide (CO), radon, volatile organic compounds
(VOCs), and ultrafine particulate matter (PM2.5), asbestos, lead, nitrogen dioxide (NO2). Figure 5 shows
the different indoor air pollution sources in our houses (Martenies and Batterman, 2018). The most
common sources are described in Figure 2.
Exposure to PM2.5 has become a substantial concern in public health because it penetrates deeply
into the respiratory tract and enters the circulatory system causing diverse health effects. Such diseases
include lung cancer, cardiovascular diseases, respiratory diseases, and increased risk for asthma exac-
erbations (Xing, 2016). Published research related to asthma has shown that asthma education, coupled
with home-based interventions and integrated pest management, has improved asthma outcomes (Baek
et al., 2019; Moreno Rangel A, 2020). The invisible indoor air pollutants in our homes can cause al-
lergic rhinitis, affecting up to 40% of people worldwide (World Allergy Organization, 2013). It happens
when our immune system reacts to allergens in the air, such as dust mites, or moulds, pollen, causing
inflammation of the nose lining (World Allergy Organization, 2013). Air pollution has a strong link with
allergy prevalence and can cause headaches, runny noses, itchy or watery eyes, and problems sleeping.
Figure 5. Indoor house air pollutants. Source: (United States Environmental Protection Agency, 2020a)
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The National Center for Healthy Housing defines a healthy home as “housing that is designed, constructed,
maintained, and rehabilitated in a manner conducive to good occupant health” (U.S. Department of
Housing and Urban Development, 2020).
We now have emerging scientific evidence associating health outcomes such as asthma, lead poi-
soning, and unintentional injuries to substandard housing. Applying Healthy Homes principles is now
essential for residents’ ongoing health; in light of this new research, its principles will help us with the
health of the persons who live in the household. All of us are familiar with the challenges that lead has
caused to children in different places where lead-paint-based was used for old buildings. As such, health
consequences for many children included damage to the brain and nervous system, slowed growth and
development, as well as learning and behavioral problems (Hauptman et al., 2017).
Houses have many hazards, not just confined to older or cheaper homes; we can identify diverse
types of risks for new or expensive housing residents. When we decide to build a new house, non-toxic
materials, safe for the individuals who will live in the house, must be selected. The new house smell is
due to the construction chemicals released into the ambient atmosphere and chemicals emitted from new
flooring, cabinets, adhesives, glues, plastics, and paint fumes. Those chemicals are off-gassed into the
indoor environment (Zhu & Liu, 2014). They will pollute the indoor environment damaging our health,
and endanger the air quality in our homes (Zhu & Liu, 2014).
Everyone wants and needs a healthy home since we spend most of our free time in our homes, so we
need to create a space that promotes children’s healthy growth and development and can save billions
in health care costs. There are particular reasons to think about children: children are growing; they
eat more food, drink more water, and breathe more air than adults; toddlers crawl and young children
play on the ground and put their fingers frequently into their mouths, and they are dependent on their
caregivers to take care of them.
The Eight Healthy Homes Principles below can help everyone make their home a healthier place to
live (Ferguson & Yates, 2016; Health and Urban Department).
1. Keep it Dry. Prevention from water entering the home’s structure and indoors through leaks in the
roof, walls, faucets, or interior plumbing will keep it dry.
2. Keep it Clean. Controlling the dust source, reducing clutter, and using a damp towel to clean will
remove the dust.
3. Keep it Safe. Storing all household chemicals that are dangerous to our children and placed them
out of their reach is essential. Installation of smoke and carbon dioxide detectors, as well as fire
extinguishers, are critical.
4. Keep it Well-Ventilated. Ventilation of the whole house is critical; open the windows to let fresh
air circulate throughout the home, preferably through the night. Use a dehumidifier or an extraction
fan in the bathroom after showering. In the kitchen, use the exhaust vent and cooking hood while
and after cooking.
5. Keep it Pest-free. The pests are similar to humans in that they look for food, water, and shelter
as we do. Therefore, look for cracks or openings in walls, windows, doors, and seal them. Store
food in airtight containers and eat only in the dining room. It is best to use sticky-traps and baits
in closed containers instead of pesticides since they are toxic or use the least toxic chemicals like
boric acid powder with sugar, but place it out of children and pets’ reach.
Energy-Ecient Homes
6. Keep it Contaminant-free. Test the house for lead and radon (a naturally occurring dangerous
gas that enters homes through soil, crawlspaces, and foundation crack).
7. Keep your home Maintained. It is important to inspect, clean, and repair the home routinely, and,
8. Thermal Controls. Ensure the indoor temperatures in the house are maintained at an adequate
temperature during cold or heat seasons. Ask a technician to check the A/C and ventilation units
to avoid increased upkeep costs and possible health problems.
Asthma and Healthy Homes education were vital in improving participantswell-being in a study
where participants increased their knowledge of asthma symptoms, case management, and identifying
triggers and exacerbating factors (Carrillo G., 2015). Krieger et al. reported improved asthma-related
health status in his Seattle-King County Healthy Homes project by reducing exposure to allergens and
irritants at home (Krieger et al., 2005).
There has been an increasing recognition that air pollution extends to indoor environments. The health
consequences caused by indoor air pollution are respiratory problems such as asthma, chronic pulmo-
nary disease, myocardial arrhythmias, and many more. Research studies have shown that children and
their families’ education with Healthy Home’s principles and asthma self-management improves health
outcomes, such as decreased hospitalizations and emergency room visits (Carrillo G, 2015). Information
about such principles will help healthcare leaders and paediatricians who serve children with asthma
understand how their patients improve their condition and decrease hospitalization costs and Emer-
gency Department visits. Furthermore, research has shown that following the healthy home principles
in households; there is an improvement in allergies and asthma symptoms, a better quality of life, and
a decreased healthcare utilization.
The chapter objectives focused on the sustainable architectural design in indoor air quality and its health
impact consequences. Accumulating evidence demonstrates a significant adverse effect on a building
environment’s energy-efficient and the unintended consequences of the health impact they caused. Re-
search has shown that exposure to indoor pollutants above certain thresholds could cause diverse health
conditions. Both building designers and occupants must manage indoor air quality through proper ven-
tilation, building materials, and cleaning products with low VOC emissions. Additionally, individuals
living in energy-efficient homes can also make preventive behaviour changes to decrease their health
impact on allergies, asthma, cardiovascular, and respiratory problems. The use of green products to clean
the homes and follow the eight principles of Healthy Homes has improved health outcomes in children
with asthma and allergies. Exposure to air pollution may result in academic performance deficiencies,
emotional and behavioural changes and generally lead to deleterious societal consequences. While ad-
ditional research is essential in larger populations to confirm recent studies, the existing data are quite
compelling. Interdisciplinary research between public health and building professionals is needed to
educate citizens and present evidence for legislative changes and recommendations to spur change to
Energy-Ecient Homes
reduce air pollution. Such policies would protect vulnerable subgroups like children, pregnant women,
the elderly population, and immunocompromised individuals to prevent these harmful effects on future
generations’ health.
This research received funding from the Research England Expanding, Excellence in England (E3) fund.
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Air pollution is the environmental public health problem of our time. The United Nations Convention on the Rights of the Child sets out clear guidance to protecting the rights of children and young people, including a child's right to the best possible health (Article 24) and the right to a good standard of living. Unicef also consider that clean air is a right for all children. The UK Royal Medical Colleges vigorously advocate for a healthy environment at the population level and in local communities, especially where socio-economic circumstances limit the choice of where people can live, and which school children attend. Despite substantial progress in understanding outdoor air pollution, the potential risk to health, especially that of children and young people, from the indoor air has been largely overlooked, yet in modern times, the indoor environment has never been more important as lockdown with the Covi-19 virus pandemic has shown us. Here we provide an abridged version of the RCPCH/RCP Report The inside story: Health effects of indoor air quality on children and young people but without the section on recommendations. The full Report along with recommendations, released on 28 January 2020, can be accessed at While we recognise that some aspects of this commentary are UK specific, much of the content has wide implications.
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Over the last decades, energy and pollution control policies combined with structural changes in the economy decoupled emission trends from economic growth, increasingly also in the developing world. It is found that effective implementation of the presently decided national pollution control regulations should allow further economic growth without major deterioration of ambient air quality, but will not be enough to reduce pollution levels in many world regions. A combination of ambitious policies focusing on pollution controls, energy and climate, agricultural production systems and addressing human consumption habits could drastically improve air quality throughout the world. By 2040, mean population exposure to PM2.5 from anthropogenic sources could be reduced by about 75% relative to 2015 and brought well below the WHO guideline in large areas of the world. While the implementation of the proposed technical measures is likely to be technically feasible in the future, the transformative changes of current practices will require strong political will, supported by a full appreciation of the multiple benefits. Improved air quality would avoid a large share of the current 3–9 million cases of premature deaths annually. At the same time, the measures that deliver clean air would also significantly reduce emissions of greenhouse gases and contribute to multiple UN sustainable development goals. This article is part of a discussion meeting issue ‘Air quality, past present and future’.
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Few studies have investigated household interventions to enhance indoor air quality (IAQ) and health outcomes in relatively low-income communities. This study aims to examine the impact of the combined intervention with asthma education and air purifier on IAQ and health outcomes in the US-Mexico border area. An intervention study conducted in McAllen, Texas, between June and November 2019 included 16 households having children with asthma. The particulate matter (PM2.5) levels were monitored in the bedroom, kitchen, and living room to measure the IAQ for 7 days before and after the intervention, respectively. Multiple surveys were applied to evaluate changes in children's health outcomes. The mean PM2.5 levels in each place were significantly improved. Overall, they significantly decreased by 1.91 μg/m3 on average (p
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One of our era's greatest scourges is air pollution, on account not only of its impact on climate change but also its impact on public and individual health due to increasing morbidity and mortality. There are many pollutants that are major factors in disease in humans. Among them, Particulate Matter (PM), particles of variable but very small diameter, penetrate the respiratory system via inhalation, causing respiratory and cardiovascular diseases, reproductive and central nervous system dysfunctions, and cancer. Despite the fact that ozone in the stratosphere plays a protective role against ultraviolet irradiation, it is harmful when in high concentration at ground level, also affecting the respiratory and cardiovascular system. Furthermore, nitrogen oxide, sulfur dioxide, Volatile Organic Compounds (VOCs), dioxins, and polycyclic aromatic hydrocarbons (PAHs) are all considered air pollutants that are harmful to humans. Carbon monoxide can even provoke direct poisoning when breathed in at high levels. Heavy metals such as lead, when absorbed into the human body, can lead to direct poisoning or chronic intoxication, depending on exposure. Diseases occurring from the aforementioned substances include principally respiratory problems such as Chronic Obstructive Pulmonary Disease (COPD), asthma, bronchiolitis, and also lung cancer, cardiovascular events, central nervous system dysfunctions, and cutaneous diseases. Last but not least, climate change resulting from environmental pollution affects the geographical distribution of many infectious diseases, as do natural disasters. The only way to tackle this problem is through public awareness coupled with a multidisciplinary approach by scientific experts; national and international organizations must address the emergence of this threat and propose sustainable solutions.
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Background: Childhood asthma is a significant health issue with 8.3% prevalence in the U.S. Its prevalence is particularly higher among low-income communities in the Texas-Mexico border region, as they often lack access to clinical care and health insurance. This study examines the impact of a home-based education led by Community Health Workers (CHWs) on health outcomes for asthmatic, predominantly Hispanic children in these communities. Methods: The study was a quasi-experimental design to learn the effectiveness of the asthma home-based education by comparing changes of health outcomes between baseline and follow-up of intervention and control groups. This study enrolled 290 participants, consisting of 130 in the intervention group and 160 in the control group. The educational intervention led by the CHWs referenced the Asthma and Healthy Homes curriculum and contents of the Seven Principles of Healthy Homes. The multiple linear regression analysis was conducted to estimate the associations between the intervention and each health outcome. Results: When comparing the intervention group with the control group, the intervention group showed a significantly greater decrease in asthma attacks than the control group (p = 0.049). Although all of the five Children's Health Survey for Asthma (CHSA) scores showed significant improvements between baseline and follow-up in both groups, we found that increases of CHSA scores in the intervention group were higher than the control group except for emotional health of children (EC) score. The multiple linear regression models demonstrated that the mean changes in asthma attacks (p = 0.036) and emotional health of families (EF) score (p = 0.038) were significantly better in the intervention group than the control group, adjusting for children's age of diagnosis, household income, use of steroids, family history of allergy, and type of insurance. Conclusions: This study concluded that the home-based education by CHWs effectively improve health outcomes among children in communities lacking access to medical resources. The findings suggest the importance of the home-based education program in promoting emotional and medical care for children and their families in low-income communities like those in the Texas-Mexico border region.
Our climate is changing at an unprecedented rate. This not only has impacts on the planet and the ecosystem, with extinction rates rising rapidly, but also on human health (Figure 1). The effects of climate change are and will continue to disrupt the basic requirements for health such as clean water, clean air, adequate food and will furthermore exacerbate underlying social, economic, and ecological
Filters can reduce indoor concentrations of particulate matter (PM2.5), but their benefits have not been well characterized. This study investigates exposure, health, and cost impacts of high efficiency filters in homes and schools, focusing on the asthma-related outcomes. Reductions in indoor exposures to PM2.5 from outdoor sources with enhanced filters (e.g., MERV 12) are estimated using probabilistic indoor air quality models, and avoided health impacts are quantified using health impact assessment. These methods are applied using data from Detroit, Michigan, an urban region with elevated asthma rates. Replacing inefficient filters with enhanced filters in schools would reduce the PM2.5-attributable asthma burden by 13% annually, with higher benefits for more efficient filters. Marginal costs average $63 per classroom or $32 per child with asthma per year. In homes, using efficient furnace filters or air cleaners yields 11 to 16% reductions in the asthma burden with an annualized marginal costs of $151 – 494 per household. Additional benefits include reductions in health risk for adults and lower exposures to other contaminants such as PM from indoor sources. Based on the included health outcomes, efficient filters in schools in particular is a potentially cost-efficient way to reduce the asthma-related health burden for children.
Global climate change, demographic change and advancing mechanization of everyday life will go along with new ways of living. Temperature extremes, an ageing society and higher demands on a comfortable life will lead to the implementation of sensor based networks in order to create acceptable and improved living conditions. Originally, the idea of the smart home served primarily the efficient use of energy and the optimization of ventilation technology connected with new ways of constructing buildings (low-energy and passive houses, respectively). Today the term 'smart home' is also linked with the networking of home automation systems, home appliances and communications and entertainment electronics. Living in a smart home often makes also significant demands on the occupants who are required to drastically change some of their living habits. This review summarizes current findings on the effect of measured environmental parameters on indoor air quality, individual thermal comfort and living behavior in smart homes with focus on central Europe. A critical evaluation of available sensor technologies, their application in homes and data security aspects as well as limits and possibilities of current technologies to control particles and gaseous pollutants indoors is included. The review also considers the acceptance of smart technologies by occupants in terms of living habits, perceived indoor air quality and data security.
Childhood lead poisoning is a multifaceted, complex condition, which affects not only the child’s health and well-being, but also the family’s housing security, economic status, job security, and stress level. This review updates the emergency department clinician on the management of childhood lead poisoning. Infants and children are at higher risk than adults for lead exposure for a number of reasons: their smaller size (and proportionately larger dose of ingested toxins), their proximity to ground dirt and indoor dust, their energy and curiosity, their oral exploratory and pica behaviors, their proportionately larger daily water and milk intake, and dietary preferences that differ markedly from those of adults. Pediatric health care providers working in the emergency department can provide medical management, as well as preventive counseling and guidance, to parents of children presenting with evidence of acute or chronic lead poisoning.