- Email: [email protected]
Impact of indoor air quality on respiratory health: results of a local survey on housing environment
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Impact of indoor air quality on respiratory health: results of a local survey on housing environment B. Levesque a,*, V. Huppe a, M. Dube a, R.C. Fachehoun a,b Institut national de sante publique du Quebec, 945 Ave. Wolfe, Quebec City, Quebec, G1V 5B3, Canada Centre integre de sante et des services sociaux de la C^ote-Nord, 835 Boulevard Jolliet, Baie-Comeau, Quebec, G5C 1P5, Canada a
b
article info
abstract
Article history:
Objectives: The ‘Mon habitat: plus qu'un simple toit’ (MHPQST) survey was designed to
Received 20 April 2018
identify public health risks and priorities for local decision makers in relation to housing.
Received in revised form
The aims of the present study were to describe the exposure of households to indoor air
6 June 2018
contaminants and to verify the relationship between these contaminants and respiratory
Accepted 19 June 2018
symptoms/diseases. Study design: This is a cross-sectional study. Methods: MHPQST was conducted in Baie-Saint-Paul, a French Canadian municipality (7000
Keywords:
inhabitants) using a protocol adapted from the ‘Large Analysis and Review of European
Indoor air
Housing and Health Status’ study performed in Europe in 2002e2003. Households were
Respiratory health
selected from two sectors (less favorable and more favorable). Data collection was achieved
Housing
using three tools (two questionnaires and one inspection grid). Indoor air variables were
Built environment
analyzed in relation to respiratory symptoms/diseases using logistic regression models
Health survey
adjusted for age, gender, income, smoking status, and proximity. Results: A total of 161 dwellings (294 inhabitants) participated in the survey. Presence of mold on walls, ceilings, or floors was detected by the investigators in 21% of the dwellings. Nearly half of the households were in contact with a pet at home and 12% with environmental tobacco smoke. Exposure to these three determinants was significantly associated with certain respiratory symptoms/diseases. Conclusion: Molds, pets at home, and environmental tobacco smoke are environmental determinants that were associated with respiratory health in the present survey. These results enabled sensitizing local stakeholders regarding the importance of indoor air quality for the respiratory health of their population. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
publique du Que bec, 945 Ave. Wolfe, Que bec City, Que bec, G1V 5B3, Canada. Tel.: þ1 * Corresponding author. Institut national de sante 418 650 5115x5214. vesque), [email protected] (V. Huppe ), [email protected] E-mail addresses: [email protected] (B. Le ), [email protected] (R.C. Fachehoun). (M. Dube https://doi.org/10.1016/j.puhe.2018.06.015 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Housing, defined as a dwelling and the surrounding environment (or residential area), is a major health determinant.1 Many authors promote the use of an integrated and collaborative approach to identify local priorities and to more effectively take action on the different risk factors associated with housing.1e4 Based on the “Large Analysis and Review of European Housing and Health Status” (LARES) protocol used by the World Health Organization (WHO) in 2002e2003 in seven European cities3,5 with the intention of identifying health risks associated with housing and action priorities for local decision makers, we conducted a survey in the municipality of BaieSaint-Paul, a French Canadian municipality of 7000 inhabitants of the province of Quebec, Canada. This survey, entitled “Mon habitat: plus qu'un simple toit (MHPQST)’ (My House: More Than Just a Roof), was the result of a collaboration between public health authorities and municipal decision makers.6 Its main purpose was to assess housing and residential area conditions that may affect health on a local basis.7 MHPQST identified specific health determinants in the studied population in addition to having a significant impact on public health in this small municipality.6 Several themes related to housing were studied. We present herein data from this study pertaining specifically to indoor air quality. The main objectives, in relation to this component, were to describe the exposure of households to indoor air determinants and to verify the relationship among these determinants and potential respiratory health issues. The methodology of the survey has already been described elsewhere.6 Two sociodemographic sectors were identified, one less favorable (sector 1) and the other more favorable (sector 2), based on a material and social deprivation index.6 A total of 673 dwellings (sector 1: 417, sector 2: 256) were eligible for the survey and were contacted. Finally, 161 households participated in the study (sector 1: 92, sector 2: 69). The survey protocol was approved by the Ethics Committee of ‘Institut publique du Que bec’ and all participants national de sante gave signed informed consent. Data collection was carried out by two interviewers during the summer of 2012,6 mainly based on a Canadian adaptation of the French version of three instruments of the LARES survey (also available in English5), namely, (1) a questionnaire completed by an investigator with an adult on the perception and satisfaction of housing; (2) a visual survey of the dwelling and surrounding environment completed by a second investigator using an inspection grid; and (3) a self-administered questionnaire on the health of occupants aged 5 years and older. The studied items were indoor air; ventilation ([1] presence of a central ventilation system, [2] low ventilation [without a central ventilation system and without one of the following two items: a functional kitchen hood/vent and a ventilator in all bathrooms/toilet rooms], and [3] inadequate ventilation habits [absence or minimal use {sometimes} of a central ventilation system and absence or minimal use {sometimes} of kitchen hood vent/bathroom ventilator(s)/ windows]); the presence of pests (mice, rats, cockroaches, bed bugs, ants, fruit flies, silverfish bugs, and others); the presence of mold (verified by the interviewer and recorded in the inspection grid); the presence of domestic animals inside the dwelling; and environmental tobacco smoke (ETS) exposure.
77
Respiratory symptoms confirmed or not by a physician during the last 12 months ([1] irritative symptoms: inflammation of the eyes, irritation of the nose, irritation of the throat; [2] rhinitis symptoms: sneezing, rhinorrhea, stuffy nose; [3] lower respiratory symptoms: respiratory difficulties, wheezing, asthma attacks) and respiratory diseases confirmed or not by a physician during the last 12 months ([1] upper respiratory diseases: cold, rhinitis, laryngitis, pharyngitis; [2] acute respiratory diseases: acute bronchitis, pneumonia, asthma) were identified and analyzed in relation to indoor air variables using multiple logistic regression models adjusted for age (age 5e25, age 26e65, age 65 and older), gender, smoking status (non-smoker, smoker), proximity (number of people/number of rooms: <0.25, 0.25- <0.5, 0.5), and income (<$30,000, $30,000- $49,999, $50,000). A total of 294 inhabitants (52% female and 48% male) living in 161 dwellings participated in the survey. The age structure was distributed as follows: 5e25 years, 14%; 26e65 years, 63%; 65, 23%. Fourteen percent of households had an income of less than $30,000, 22% had a household income between $30,000 and $49,999, and 64%, a household income of $50,000 or more. The investigators noted the presence of mold on walls, ceilings, or floors; signs of water infiltration; and mold odor in, respectively, 20.6%, 16.3%, and 12.5% of the dwellings visited. A proportion of 13% of households were affected by water damage in the past year, while 5.7% of the roofs were considered not waterproof by the occupant. Nearly half of the households (47.8%) had a pet (dog or cat) inside the home and in 11.9% of dwellings, people were exposed to ETS of at least one cigarette a day. Proportions of 66.3%, 22.2%, and 13.2% of the dwellings, respectively, were not equipped with a central ventilation system, a fan in at least one bathroom, and a functional kitchen hood vent. A number of 38 households were affected by a pest problem (mice, rats, cockroaches, bed bugs, ants, fruit flies, silverfish bugs, and others). Among the pest problems, the prevalence of households declaring rodents (rats, n ¼ 1; mice, n ¼ 8) or cockroaches (n ¼ 2), some pests more related to respiratory problems,5 was low. Results of adjusted models between indoor air variables and respiratory symptoms/diseases are provided in Table 1. Only indoor air variables that were significantly related with at least one dependent variable were included. The presence of mold documented by the investigator was significantly associated with physician-confirmed symptoms of rhinitis and rhinitis symptoms that subsided outside the home. Exposure to cats and dogs inside the dwelling was associated with lower respiratory symptoms but also with upper respiratory diseases that had not been confirmed by a physician. In contrast, exposure to ETS was related with physicianconfirmed upper respiratory illnesses, physician-confirmed acute bronchitis/pneumonia, and asthma attacks. No significant associations were documented with the variables associated with ventilation or pests. Overall, the prevalence of mold observed in this survey appears to be within the range generally documented around the world. D'Halewyn et al. reported a prevalence of excessive moisture and/or mold between 14% and 38% of dwellings in North America and Europe,8 which is similar to the results of a more recent study of the WHO, which reports proportions
78
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Table 1 e Respiratory symptoms/diseases during the last 12 months in relation with indoor air contaminants. Respiratory symptoms/ diseases
Irritative respiratory symptoms confirmed by a physician Irritative respiratory symptoms Rhinitis symptoms confirmed by a physician Rhinitis symptoms Rhinitis symptoms that decreased outside the home Lower respiratory symptoms confirmed by a physician Lower respiratory symptoms Upper respiratory diseases confirmed by a physician Upper respiratory diseases Acute bronchitis or pneumonia confirmed by a physician Asthma confirmed by a physician Asthma crisis
Mold walls/ceilings/floors
Indoor exposure to cats or dogs
Indoor exposure to environmental tobacco smoke
aOR (95% CI)a P-value
aOR (CI 95%) P-value
aOR (CI 95%) P-value
1.14 (0.40e3.29) P ¼ 0.8063
0.89 (0.32e2.49) P ¼ 0.8245
3.27 (0.61e17.65) P ¼ 0.1688
2.02 (0.92e4.41) P ¼ 0.0789 2.90 (1.04e8.12) P ¼ 0.0425
0.89 (0.42e1.90) P ¼ 0.7634 1.01 (0.40e2.56) P ¼ 0.9844
0.96 (0.30e3.15) P ¼ 0.9522 2.43 (0.79e7.51) P ¼ 0.1237
1.87 (0.94e3.71) P ¼ 0.0749 3.62 (1.18e11.09) P ¼ 0.0245
1.24 (0.71e2.16) P ¼ 0.4440 1.08 (0.22e5.27) P ¼ 0.9254
0.95 (0.40e2.26) P ¼ 0.8999 0.35 (0.03e3.61) P ¼ 0.3746
0.58 (0.09e3.58) P ¼ 0.5571
3.06 (0.98e9.57) P ¼ 0.0543
1.54 (0.48e4.97) P ¼ 0.4739
0.83 (0.25e2.73) P ¼ 0.7623 0.71 (0.07e6.91) P ¼ 0.7694
2.50 (1.08e5.78) P ¼ 0.0321 1.22 (0.40e3.75) P ¼ 0.7273
1.24 (0.43e3.56) P ¼ 0.6870 4.90 (1.21e19.83) P ¼ 0.0258
2.08 (0.86e5.04) P ¼ 0.1063 1.36 (0.37e5.07) P ¼ 0.6463
2.42 (1.14e5.11) P ¼ 0.0207 0.71 (0.24e2.11) P ¼ 0.5390
0.41 (0.13e1.27) P ¼ 0.1224 4.26 (1.15e15.82) P ¼ 0.0302
1.36 (0.43e4.26) P ¼ 0.5973 0.67 (0.13e3.55) P ¼ 0.6376
2.14 (0.67e6.84) P ¼ 0.1978 1.40 (0.37e5.26) P ¼ 0.6214
2.05 (0.61e6.85) P ¼ 0.2428 5.22 (1.28e21.27) P ¼ 0.0210
aOR, adjusted odds ratio; CI, confidence interval. a Adjusted odds ratio (age, gender, smoking status, proximity, income) with the 95% confidence interval.
varying from 15 to 30% in Europe.9 Several favorable conditions for mold growth (e.g. signs of infiltration, history of water damage over the last 12 months) have been observed in the surveyed dwellings. Over time, these can cause mold to proliferate and pose a significant risk to respiratory health for occupants, hence the importance of taking charge of the problem quickly. Moreover, of note, in households where mold was observed on the walls, ceilings, or floors by the investigators, occupants reported more health problems compatible with mold exposure and that these problems decreased outside the home (Table 1). Although there was no statistical relationship between respiratory health problems and the variables regarding ventilation, when the home was not equipped with a central ventilation system, the investigator was more likely to observe the presence of mold on walls (P ¼ 0.03; data not presented). Moreover, when the ventilation capacity of the dwelling was considered to be low (without a central ventilation system and without one of the following two items: a functional kitchen hood/vent and a ventilator in all bathrooms/toilet rooms), the investigator was more likely to perceive a smell of mold (P ¼ 0.01; data not presented) and more frequently observed mold on walls, ceilings, and floors (P ¼ 0.05; data not presented). This highlights the importance of having ventilation devices, at least for the extraction of moisture and contaminants at the source (e.g. functional kitchen hood vents with external outlet) to ensure indoor air quality. Nearly one in two households owned a pet. The presence of allergens in indoor environments can become problematic for sensitized individuals, who are subsequently likely to develop more symptoms or diseases related to allergies, including asthma. It is, therefore, not surprising that there were some relationships with lower respiratory symptoms and upper
respiratory symptoms, which, however, were not confirmed by a physician (Table 1). The best preventive measure is to remove the animal from the home. ETS exposure was associated with upper respiratory diseases confirmed by a physician, clinically confirmed bronchitis/pneumonia and reported asthma attacks in the past 12 months (Table 1). These data highlight the importance of this modifiable determinant of respiratory health in relation to indoor air quality.10 In this survey, for 47.5% of households including a smoker, one or more occupants smoked cigarettes inside the dwelling. While the MHPQST survey was used as a tool to identify health priorities,6 it also served to sensitize local authorities and the population regarding specific health determinants related to housing, including elements associated with indoor air quality such as exposure to mold, animal allergens, and ETS which were identified in this survey with the same level of concern. Moreover, these locally harvestedebased data were consistent with the literature, demonstrating the quality of the methods used and helping to crystallize the confidence of local stakeholders in their decisions based on the results of the survey.6
Author statements Acknowledgments MHPQST was financially supported by the Institut National de publique du Que bec. The authors would like to thank all sante of their colleagues who worked to the conducting of the survey, from the writing of the protocol up to the final report. Finally, sincere thanks to the population of Baie-Saint-Paul including the City Council and in particular, the survey participants.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Ethical approval The survey protocol was approved by the Ethics Committee of publique du Que bec. All participants Institut national de sante provided informed consent.
Funding The MHPQST survey was financially supported by the Institut publique du Que bec. National de sante
Competing interests None declared.
references
1. U.S. Department of Health and Human Services. The Surgeon General's call to action to promote healthy homes. Department of Health and Human Services. Office of the Surgeon General; 2009. 2. Shaw M. Housing and public health. Annu Rev Public health 2004;25:397e418.
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3. Bonnefoy X, Braubach M, Davidson M, Robbel N. A panEuropean housing and health survey: description and evaluation of methods and approaches. Int J Environ Pollut 2007;30:363e83. 4. Lubell J, Morley R, Ashe M, Merola L, Levi J. Housing and health: new opportunities for dialogue and action. [Internet]. National Center for Healthy Housing; 2012. http://www.nchh.org/ Portals/0/HHFF_Housing_and_Health_New_Opportunities.pdf [cited 2016 Jan 16]. 5. Ormandy D, editor. Housing and health in Europe: the WHO LARES project. London, England: Routledge Taylor & Francis; 2009. vesque B, Huppe V, Tourigny A. Mobilizing local authorities 6. Le around public health priorities. Am J Public Health 2016;106:1233e4. publique du Que bec (INSPQ). Mon 7. Institut national de sante habitat: plus qu’un simple toit: resultats du projet pilote de Baie publique du Saint-Paul. [Internet]. Institut national de sante bec; 2014. https://www.inspq.qc.ca/pdf/publications/ Que 1802_Mon_Habitat.pdf [cited 2016 Jan 16]. 8. D'Halewyn MA, Leclerc JM, King N, Legris M, Frenette Y. Les la sante associes a la presence de moisissures en milieu risques a publique du Que bec; 2002. interieur. Institut national de sante 9. World Health Organization. Local housing and health action plans- a project manual. World Health Organization; 2007. 10. Giraldi G, Fovi De Ruggiero G, Marsella LT, De Luca d'Alessandro E. Environmental tobacco smoke: health policy and focus on Italian legislation. Clin Ter 2013;164:e429e35.
Available online at www.sciencedirect.com
Public Health journal homepage: www.elsevier.com/puhe
Short Communication
Impact of indoor air quality on respiratory health: results of a local survey on housing environment B. Levesque a,*, V. Huppe a, M. Dube a, R.C. Fachehoun a,b Institut national de sante publique du Quebec, 945 Ave. Wolfe, Quebec City, Quebec, G1V 5B3, Canada Centre integre de sante et des services sociaux de la C^ote-Nord, 835 Boulevard Jolliet, Baie-Comeau, Quebec, G5C 1P5, Canada a
b
article info
abstract
Article history:
Objectives: The ‘Mon habitat: plus qu'un simple toit’ (MHPQST) survey was designed to
Received 20 April 2018
identify public health risks and priorities for local decision makers in relation to housing.
Received in revised form
The aims of the present study were to describe the exposure of households to indoor air
6 June 2018
contaminants and to verify the relationship between these contaminants and respiratory
Accepted 19 June 2018
symptoms/diseases. Study design: This is a cross-sectional study. Methods: MHPQST was conducted in Baie-Saint-Paul, a French Canadian municipality (7000
Keywords:
inhabitants) using a protocol adapted from the ‘Large Analysis and Review of European
Indoor air
Housing and Health Status’ study performed in Europe in 2002e2003. Households were
Respiratory health
selected from two sectors (less favorable and more favorable). Data collection was achieved
Housing
using three tools (two questionnaires and one inspection grid). Indoor air variables were
Built environment
analyzed in relation to respiratory symptoms/diseases using logistic regression models
Health survey
adjusted for age, gender, income, smoking status, and proximity. Results: A total of 161 dwellings (294 inhabitants) participated in the survey. Presence of mold on walls, ceilings, or floors was detected by the investigators in 21% of the dwellings. Nearly half of the households were in contact with a pet at home and 12% with environmental tobacco smoke. Exposure to these three determinants was significantly associated with certain respiratory symptoms/diseases. Conclusion: Molds, pets at home, and environmental tobacco smoke are environmental determinants that were associated with respiratory health in the present survey. These results enabled sensitizing local stakeholders regarding the importance of indoor air quality for the respiratory health of their population. © 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
publique du Que bec, 945 Ave. Wolfe, Que bec City, Que bec, G1V 5B3, Canada. Tel.: þ1 * Corresponding author. Institut national de sante 418 650 5115x5214. vesque), [email protected] (V. Huppe ), [email protected] E-mail addresses: [email protected] (B. Le ), [email protected] (R.C. Fachehoun). (M. Dube https://doi.org/10.1016/j.puhe.2018.06.015 0033-3506/© 2018 The Royal Society for Public Health. Published by Elsevier Ltd. All rights reserved.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Housing, defined as a dwelling and the surrounding environment (or residential area), is a major health determinant.1 Many authors promote the use of an integrated and collaborative approach to identify local priorities and to more effectively take action on the different risk factors associated with housing.1e4 Based on the “Large Analysis and Review of European Housing and Health Status” (LARES) protocol used by the World Health Organization (WHO) in 2002e2003 in seven European cities3,5 with the intention of identifying health risks associated with housing and action priorities for local decision makers, we conducted a survey in the municipality of BaieSaint-Paul, a French Canadian municipality of 7000 inhabitants of the province of Quebec, Canada. This survey, entitled “Mon habitat: plus qu'un simple toit (MHPQST)’ (My House: More Than Just a Roof), was the result of a collaboration between public health authorities and municipal decision makers.6 Its main purpose was to assess housing and residential area conditions that may affect health on a local basis.7 MHPQST identified specific health determinants in the studied population in addition to having a significant impact on public health in this small municipality.6 Several themes related to housing were studied. We present herein data from this study pertaining specifically to indoor air quality. The main objectives, in relation to this component, were to describe the exposure of households to indoor air determinants and to verify the relationship among these determinants and potential respiratory health issues. The methodology of the survey has already been described elsewhere.6 Two sociodemographic sectors were identified, one less favorable (sector 1) and the other more favorable (sector 2), based on a material and social deprivation index.6 A total of 673 dwellings (sector 1: 417, sector 2: 256) were eligible for the survey and were contacted. Finally, 161 households participated in the study (sector 1: 92, sector 2: 69). The survey protocol was approved by the Ethics Committee of ‘Institut publique du Que bec’ and all participants national de sante gave signed informed consent. Data collection was carried out by two interviewers during the summer of 2012,6 mainly based on a Canadian adaptation of the French version of three instruments of the LARES survey (also available in English5), namely, (1) a questionnaire completed by an investigator with an adult on the perception and satisfaction of housing; (2) a visual survey of the dwelling and surrounding environment completed by a second investigator using an inspection grid; and (3) a self-administered questionnaire on the health of occupants aged 5 years and older. The studied items were indoor air; ventilation ([1] presence of a central ventilation system, [2] low ventilation [without a central ventilation system and without one of the following two items: a functional kitchen hood/vent and a ventilator in all bathrooms/toilet rooms], and [3] inadequate ventilation habits [absence or minimal use {sometimes} of a central ventilation system and absence or minimal use {sometimes} of kitchen hood vent/bathroom ventilator(s)/ windows]); the presence of pests (mice, rats, cockroaches, bed bugs, ants, fruit flies, silverfish bugs, and others); the presence of mold (verified by the interviewer and recorded in the inspection grid); the presence of domestic animals inside the dwelling; and environmental tobacco smoke (ETS) exposure.
77
Respiratory symptoms confirmed or not by a physician during the last 12 months ([1] irritative symptoms: inflammation of the eyes, irritation of the nose, irritation of the throat; [2] rhinitis symptoms: sneezing, rhinorrhea, stuffy nose; [3] lower respiratory symptoms: respiratory difficulties, wheezing, asthma attacks) and respiratory diseases confirmed or not by a physician during the last 12 months ([1] upper respiratory diseases: cold, rhinitis, laryngitis, pharyngitis; [2] acute respiratory diseases: acute bronchitis, pneumonia, asthma) were identified and analyzed in relation to indoor air variables using multiple logistic regression models adjusted for age (age 5e25, age 26e65, age 65 and older), gender, smoking status (non-smoker, smoker), proximity (number of people/number of rooms: <0.25, 0.25- <0.5, 0.5), and income (<$30,000, $30,000- $49,999, $50,000). A total of 294 inhabitants (52% female and 48% male) living in 161 dwellings participated in the survey. The age structure was distributed as follows: 5e25 years, 14%; 26e65 years, 63%; 65, 23%. Fourteen percent of households had an income of less than $30,000, 22% had a household income between $30,000 and $49,999, and 64%, a household income of $50,000 or more. The investigators noted the presence of mold on walls, ceilings, or floors; signs of water infiltration; and mold odor in, respectively, 20.6%, 16.3%, and 12.5% of the dwellings visited. A proportion of 13% of households were affected by water damage in the past year, while 5.7% of the roofs were considered not waterproof by the occupant. Nearly half of the households (47.8%) had a pet (dog or cat) inside the home and in 11.9% of dwellings, people were exposed to ETS of at least one cigarette a day. Proportions of 66.3%, 22.2%, and 13.2% of the dwellings, respectively, were not equipped with a central ventilation system, a fan in at least one bathroom, and a functional kitchen hood vent. A number of 38 households were affected by a pest problem (mice, rats, cockroaches, bed bugs, ants, fruit flies, silverfish bugs, and others). Among the pest problems, the prevalence of households declaring rodents (rats, n ¼ 1; mice, n ¼ 8) or cockroaches (n ¼ 2), some pests more related to respiratory problems,5 was low. Results of adjusted models between indoor air variables and respiratory symptoms/diseases are provided in Table 1. Only indoor air variables that were significantly related with at least one dependent variable were included. The presence of mold documented by the investigator was significantly associated with physician-confirmed symptoms of rhinitis and rhinitis symptoms that subsided outside the home. Exposure to cats and dogs inside the dwelling was associated with lower respiratory symptoms but also with upper respiratory diseases that had not been confirmed by a physician. In contrast, exposure to ETS was related with physicianconfirmed upper respiratory illnesses, physician-confirmed acute bronchitis/pneumonia, and asthma attacks. No significant associations were documented with the variables associated with ventilation or pests. Overall, the prevalence of mold observed in this survey appears to be within the range generally documented around the world. D'Halewyn et al. reported a prevalence of excessive moisture and/or mold between 14% and 38% of dwellings in North America and Europe,8 which is similar to the results of a more recent study of the WHO, which reports proportions
78
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Table 1 e Respiratory symptoms/diseases during the last 12 months in relation with indoor air contaminants. Respiratory symptoms/ diseases
Irritative respiratory symptoms confirmed by a physician Irritative respiratory symptoms Rhinitis symptoms confirmed by a physician Rhinitis symptoms Rhinitis symptoms that decreased outside the home Lower respiratory symptoms confirmed by a physician Lower respiratory symptoms Upper respiratory diseases confirmed by a physician Upper respiratory diseases Acute bronchitis or pneumonia confirmed by a physician Asthma confirmed by a physician Asthma crisis
Mold walls/ceilings/floors
Indoor exposure to cats or dogs
Indoor exposure to environmental tobacco smoke
aOR (95% CI)a P-value
aOR (CI 95%) P-value
aOR (CI 95%) P-value
1.14 (0.40e3.29) P ¼ 0.8063
0.89 (0.32e2.49) P ¼ 0.8245
3.27 (0.61e17.65) P ¼ 0.1688
2.02 (0.92e4.41) P ¼ 0.0789 2.90 (1.04e8.12) P ¼ 0.0425
0.89 (0.42e1.90) P ¼ 0.7634 1.01 (0.40e2.56) P ¼ 0.9844
0.96 (0.30e3.15) P ¼ 0.9522 2.43 (0.79e7.51) P ¼ 0.1237
1.87 (0.94e3.71) P ¼ 0.0749 3.62 (1.18e11.09) P ¼ 0.0245
1.24 (0.71e2.16) P ¼ 0.4440 1.08 (0.22e5.27) P ¼ 0.9254
0.95 (0.40e2.26) P ¼ 0.8999 0.35 (0.03e3.61) P ¼ 0.3746
0.58 (0.09e3.58) P ¼ 0.5571
3.06 (0.98e9.57) P ¼ 0.0543
1.54 (0.48e4.97) P ¼ 0.4739
0.83 (0.25e2.73) P ¼ 0.7623 0.71 (0.07e6.91) P ¼ 0.7694
2.50 (1.08e5.78) P ¼ 0.0321 1.22 (0.40e3.75) P ¼ 0.7273
1.24 (0.43e3.56) P ¼ 0.6870 4.90 (1.21e19.83) P ¼ 0.0258
2.08 (0.86e5.04) P ¼ 0.1063 1.36 (0.37e5.07) P ¼ 0.6463
2.42 (1.14e5.11) P ¼ 0.0207 0.71 (0.24e2.11) P ¼ 0.5390
0.41 (0.13e1.27) P ¼ 0.1224 4.26 (1.15e15.82) P ¼ 0.0302
1.36 (0.43e4.26) P ¼ 0.5973 0.67 (0.13e3.55) P ¼ 0.6376
2.14 (0.67e6.84) P ¼ 0.1978 1.40 (0.37e5.26) P ¼ 0.6214
2.05 (0.61e6.85) P ¼ 0.2428 5.22 (1.28e21.27) P ¼ 0.0210
aOR, adjusted odds ratio; CI, confidence interval. a Adjusted odds ratio (age, gender, smoking status, proximity, income) with the 95% confidence interval.
varying from 15 to 30% in Europe.9 Several favorable conditions for mold growth (e.g. signs of infiltration, history of water damage over the last 12 months) have been observed in the surveyed dwellings. Over time, these can cause mold to proliferate and pose a significant risk to respiratory health for occupants, hence the importance of taking charge of the problem quickly. Moreover, of note, in households where mold was observed on the walls, ceilings, or floors by the investigators, occupants reported more health problems compatible with mold exposure and that these problems decreased outside the home (Table 1). Although there was no statistical relationship between respiratory health problems and the variables regarding ventilation, when the home was not equipped with a central ventilation system, the investigator was more likely to observe the presence of mold on walls (P ¼ 0.03; data not presented). Moreover, when the ventilation capacity of the dwelling was considered to be low (without a central ventilation system and without one of the following two items: a functional kitchen hood/vent and a ventilator in all bathrooms/toilet rooms), the investigator was more likely to perceive a smell of mold (P ¼ 0.01; data not presented) and more frequently observed mold on walls, ceilings, and floors (P ¼ 0.05; data not presented). This highlights the importance of having ventilation devices, at least for the extraction of moisture and contaminants at the source (e.g. functional kitchen hood vents with external outlet) to ensure indoor air quality. Nearly one in two households owned a pet. The presence of allergens in indoor environments can become problematic for sensitized individuals, who are subsequently likely to develop more symptoms or diseases related to allergies, including asthma. It is, therefore, not surprising that there were some relationships with lower respiratory symptoms and upper
respiratory symptoms, which, however, were not confirmed by a physician (Table 1). The best preventive measure is to remove the animal from the home. ETS exposure was associated with upper respiratory diseases confirmed by a physician, clinically confirmed bronchitis/pneumonia and reported asthma attacks in the past 12 months (Table 1). These data highlight the importance of this modifiable determinant of respiratory health in relation to indoor air quality.10 In this survey, for 47.5% of households including a smoker, one or more occupants smoked cigarettes inside the dwelling. While the MHPQST survey was used as a tool to identify health priorities,6 it also served to sensitize local authorities and the population regarding specific health determinants related to housing, including elements associated with indoor air quality such as exposure to mold, animal allergens, and ETS which were identified in this survey with the same level of concern. Moreover, these locally harvestedebased data were consistent with the literature, demonstrating the quality of the methods used and helping to crystallize the confidence of local stakeholders in their decisions based on the results of the survey.6
Author statements Acknowledgments MHPQST was financially supported by the Institut National de publique du Que bec. The authors would like to thank all sante of their colleagues who worked to the conducting of the survey, from the writing of the protocol up to the final report. Finally, sincere thanks to the population of Baie-Saint-Paul including the City Council and in particular, the survey participants.
p u b l i c h e a l t h 1 6 3 ( 2 0 1 8 ) 7 6 e7 9
Ethical approval The survey protocol was approved by the Ethics Committee of publique du Que bec. All participants Institut national de sante provided informed consent.
Funding The MHPQST survey was financially supported by the Institut publique du Que bec. National de sante
Competing interests None declared.
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