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

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

C. Hostland1, G. Lovegrove2, D. Roberts3

PhD graduate student Civil Engineering, School of Engineering, University of British Columbia Okanagan, Kelowna, BC Canada V1V 1V7, E-mail: craig.hostland@alumni.ubc.ca 2 Assistant Professor, School of Engineering, University of British Columbia Okanagan, Kelowna, BC Canada V1V 1V7, E-mail: gord.lovegrove@ubc.ca 3 Associate Professor Associate Director: Graduate Studies and Research, , School of Engineering, University of British Columbia Okanagan, Kelowna, BC Canada V1V 1V7, E-mail: Deborah.roberts@ubc.ca

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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 pilot projects and health studies conclude that better indoor environments translate to better well-being through lower incidence of ill-health and higher productivity in the workplace which result in fewer doctor and emergency room visits and reduced hospital stays as well as lower direct and indirect costs to businesses. Specifically, a number of effects have been studied with toxic mould in damp homes found to significantly increase the incidence of chronic asthma conditions with a direct and consequential impact on the health care system. Removing toxic mould in damp homes not only translates into a reduced burden on a society that funds universal health care but this paper concludes a potentially significant net social cost/benefit by taking a proactive approach to addressing toxic mould in built structures. The residential toxic mould burden on North 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 from homes 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 of billions of dollars per year when the issue is expanded to include commercial, financial, and social based impacts. Based on results, this paper recommends further investigation into solutions 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 toxins health 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 the largest contributors being: biological agents such as toxic mould (mycotoxins, MVOCs); volatile chemicals (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 are easily avoidable if recognized by the occupant as such and dealt with promptly given adequate direction and ways and means (Samet et al. 2003). But non-recognition and therefore non-action is a common inhibitor in the removal of such toxins from our environment. In particular, with no recognized 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 is not 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 commonly reported in built structures (homes, schools, hospitals, etc) with an association between dampness or mould and adverse health effects noted (Bernstein et al. 2008). Residential dampness and mould are associated with substantial and statistically significant increases in both respiratory infections and bronchitis (Fisk WJ., 2010 p. 4). Fisk further states that effective control of dampness and mould in buildings would prevent a substantial proportion of respiratory infections. According to Verhoeff (1997) fungi (mould) does cause allergenic disease. Canadian homes have a high prevalence (38%) of dampness or moulds present (Dales, 1991). US homes have a corresponding prevalence.

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

A cost/ benefit analysis requires an ability to measure and quantify the impact of toxic moulds in homes on society. This is, in part, accomplished by measuring health care costs attributable to toxic moulds in homes. Recent research provides limited but consequential quantified statistics pertaining specifically to mould, its impact on residential occupants, and its impact 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 association exists between dampness and mould in homes and respiratory diseases.

The detailed literature review conducted for this paper exposes a direct relationship between asthma 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 and residential studies. Further, it is found that asthma constitutes a significant percentage of measured 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 related ill-health to toxic mould in indoor environments but also to health care costs in a measurable way. There are a number of other indirect causal effects that as well can contribute to the increased benefit of removing toxic moulds from homes, such as reduction in: anemia; general malaise; lost work days; reduced efficiency; and reduction in mental health impacts in the population that will be reviewed in a further study.
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Numerous commercial environment based technical papers, regulations, and standards exist for hundreds of chemicals, noxious gases, VOCs, and biological agents; but only a few technical papers and no standards or regulations exist for these health hazards, let alone mould, in homes as very few jurisdictions have enacted health and safety based regulations and those who have significantly 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 exposure risks are similar between that found in buildings and that found in homes. This paper relies on this assertion; but the comprehensive adaptation of industry standards to residential environments adjusted for conditions requires further research to ensure accuracy of comparatives.

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 was specifically excluded from this paper. The more pertinent results of the literature review are provided 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 Respiratory symptoms increase with indoor mould dampness and mould Jaakkola et al (2002) CDC (2002) Kercsmar et al (2006) Fisk et al (2007) Hope & Simon (2007) Howden Indoor dampness and Increased risk of asthma in damp or mold molds in homes containing indoor environments Prevalence of asthma Increase in asthma prevalence from 1980 in general population 1999. Noted success in intervention programs. Indoor dampness and Reduction of asthma symptoms mould environmental remediation after

Indoor dampness and Association between asthma, mold and sick mould buildings Indoor dampness and Respiratory symptoms with indoor dampness mould and mould dampness, Marked decrease in doctor/ hospital visits
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Chapman Indoor

(2007) Health Canada (2007)

cold and respiratory after renovation symptoms Indoor mould Association with asthma symptoms damp Association with asthma, respiratory symptoms allergy, and

NYC (2008), Koskinen Indoor et al. (1999) environments

Sakakian, Park, Cox- Indoor dampness and Association between dampness, mould, and Ganser (2008) mould asthma. Fisk et al (2010) Cabral (2010) Pongracic et al (2010) Indoor dampness and Statistically significant increase in respiratory mould infections. Indoor dampness and Association between fungal growth and sick airborne fungi houses and buildings Fungal contamination Association with cause of poor asthma and in homes need for home renovations

Current knowledge supports the need to prevent damp conditions and mould growth and to remediate 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-identification of mould from damp buildings and the associated epidemic of building related ill-health in the general North American population. Critically, the present health care profession is mute on the consequential relationship between ill-health and indoor environments; as exhibited by its absence 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 related sickness is not routinely collected as there is no specific ICD code that defines it in the hospital admissions 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, or are thwarted by waiting room line-ups and available appointment time. With or without medical treatment, the afflicted continue to function at a reduced rate and remain compromised when conducting 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 is adversely impacted each time the health care system is accessed or demand is elevated due to a specific causal effect, each time subsidized drugs and treatments are prescribed and each time someone loses their ambulatory abilities and health care services are called upon to assist in dayPage 6 of 25

to-day required activities; but society is also adversely affected when the impact remains silent to the 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 complaints of SBS related sickness were not positively addressed by building landlords nor by the BC Residential Tenancy (RTO 2011) complaints process even when verified mould environments were professionally documented (Hostland 2010). Without options to move (low vacancy rate or lack of available funds to relocate) and no recourse through medical or government assistance programs, tenants literally remain confined to environments that make them and their children sick - 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 of social support is not easily broken by a system that does not recognize the plight of the working poor 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 three million children in the US (Kercsmar et al. 2006). Documented to be a by-product of unhealthy home environments (Daisey et al. 2003; Engvall et al. 2001; Nafstad et al. 1998; Perry et 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) exacerbated by dampness and moulds in homes (Dales et al. 1991, Fisk et al. 2007,2010). The objectives of this paper to consider the connections between toxic moulds in damp homes, the cost burden on the healthcare system, and the net social cost/ benefit of resolving this issue proactively will be addressed utilizing Government published hospitalization records and peer reviewed journal studies.

Asthma based health records are well defined within the American health field but not so clearly 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 cost benefit analysis based on a preventative health care model to bring better IAQ into homes in a sustainable way in Canada and more specifically into British Columbia. Existing residential based research will be supplemented further with studies that focus particularly on mould types or extent of airborne and surface dwelling toxic moulds that correlate to SBS type health responses in homes and commercial workplace environments which will help to provide deeper clarity and perspective that does not now exist.
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Research studies conducted to date associate mould with asthma and ill-health at a statistical 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 odds ratio is the ratio of the odds of an event occurring in one group to the odds of it occurring in another 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 used to 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 rate ratio in epidemiology is calculated to compare the ratio of events occurring ( ie Incidence Rate 1/Incidence Rate 2). Incidence is a measure of the risk of developing some new condition within a specified period of time. Although sometimes loosely expressed simply as the number of new cases during some time period, it is better expressed as a proportion or a rate with a denominator with higher values indicating a higher risk of developing the condition. Table 3-1 -- Epidemiologic studies investigating an association between indoor dampness or mold and new-onset asthma or new-onset asthma-like symptoms that use odds ratios as a measure of risk (Sahakian et al. 2008) Reference Adults
Flodin and Jnsson Longitudinal case- Reported workplace New-onset physiciancontrol study (2065 dampness (mold or moisture diagnosed asthma at age years old) damage)[a] 2065 years

Study design

Environmental exposure

Health outcome

Odds ratio (95% CI) 4.7 (1.514.3)

Gunnbjrnsdttir Prospective study Reported dampness (water et al with a 7.9-year damage, leakage, or mold follow-up period growth) in the home[b] (mean age at follow up: 40 years)

New-onset asthma attack or current use of asthma medications[c] New-onset wheeze[c] New-onset nocturnal dyspnea[c] New-onset nocturnal cough[c]

1.1 (0.91.4) 1.3 (1.11.5) 1.3 (1.11.6) 1.3 (1.11.4) 1.4 (0.92.1) 4.6 (1.119.4)

Jaakkola et al

Population-based incident case-control study (2163 years old)

Reported visible mold or mold odor at work[c] and No wall-to-wall carpet at work Wall-to-wall carpet at work

New-onset physiciandiagnosed asthma with both reversible airways obstruction and a history of at least one asthma-like symptom

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
a birth cohort from age 2 months to 2 years of age

Environmental exposure
windowpane condensation, visible mold, or mold odor when child was 2 months of age

Health outcome
wheezing after age 3 months and either use of inhaled steroids or symptoms suggestive of bronchial hyper-reactivity

Odds ratio (95% CI)

Emenius et al

Nested case-control One sign of dampness based study of a birth on home inspection cohort (2 years old) Three or more signs of dampness based on home inspection Population-based Mold odor based on current incident case-control home inspection study (17 years old) Visible mold based on current home inspection Visible mold in main living area based on current home inspection Water damage in main living area based on current home inspection

Three or more episodes of wheezing after age 3 months and either use of inhaled steroids or symptoms suggestive of bronchial hyper-reactivity New-onset physiciandiagnosed asthma or new referral to hospital after two or more attacks of wheezing

1.3 (0.82.2) 2.7 (1.35.4)

Pekkanen et al

4.1 (0.626.0) 1.2 (0.72.1) 2.6 (1.25.8) 2.2 (1.24.0)

a b c

Present for 3 or more years and occurred at least 3 years before year of asthma diagnosis. Present any time in between the initial and follow-up survey. Present during the past year.

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

Reference Adults
Cox-Ganser et al

Study design

Environmental exposure

Incidence rate ratio (95% CI) 7.5 (no CI)

Cross-sectional study with information on dates of hire and asthma diagnosis (mean age 46 years)

Office building with water damage and mold contamination based on building inspection

White et al

Cross-sectional study with information on dates of hire and asthma diagnosis (mean age 48

School building with evidence of water damage and mold contamination based on building inspection

8.5 (no CI)

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Reference
years)

Study design

Environmental exposure

Incidence rate ratio (95% CI)

Children Jaakkola et al Population-based cohort study with Reported mold odor in the home[b] [a] a 6-year follow-up period (17 years Reported visible mold in the home[b] old at baseline) Reported moisture on surfaces in the home[b] Reported water damage in the home[b] Any of above dampness indicators

2.4 (1.15.6) 0.6 (0.21.7) 0.9 (0.51.5) 1.0 (0.42.3) 1.0 (0.71.5)

a b

Cited in Fisk WJ, Lei-Gomez Q, Mendell MJ. Meta-analyses of the associations of respiratory health effects with dampness and mold in homes. Indoor Air 2007;17:28496. 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 cost of 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 indoor environments requires measurement of effects. The major effects are: respiratory disease; allergy and asthma symptoms; sick building syndrome (SBS); and worker performance. The cost of these major effects on patients in society will culminate in a financial impact to society ( directly in 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. As well, 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 on productivity gains which will be addressed in the next section. The assumptions used to compare to 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 homes remediated; 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 table 051-0001

Determining the impact of mould affected homes on the health care system can be determined through the PHAC and CDC asthma statistics although the value of the impact will only be on the smaller population of asthmatics. Another method would be to use the causal relationship between damp homes and mould growth with cumulative statistical information provided 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 mold exposure. This valuation is used comparatively to assess the impact of mould in asthma related residential based environmental ill-health.

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

Canadian statistics identifies asthma hospitalization rates to be approx. 280/100,000 of population for adults 25+ and 1,400 /100,000 for children 0-24 yrs. (PHAC 2007). Statistics Canada sets the population of 0-24 yr to be 10,077,400 (2004) and 25+ 21,868,900 (2004) to be for 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 standard ward 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 to address pre and post visits with these costs in the range of $ 500 - $ 1000 a year for the Provincial (MSA) portion. Using these rates and an average year to year ACV of 1.4 x 2.5 overnights per visit and a standard ward charge of 1 night critical care and 1.5 nights standard ward 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 affected occupants home once for $3,500 - $ 5,000, ( less than a 6 month payback on average) rather than continue to address the ill-health of that patient over the years they continue to reside in that health 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 the asthma based health impact attributable to mould in built environments, and taking the cost of care value noted above, the health regions Canadian wide cost of care is a little over 532 million dollars. This would remediate 106,520 mould infested home environments per year and reduce the impact on health care in the first year by $ 799 million dollars. The present worth of these Page 12 of 25

values can be considered in reducing demand projections and thereby reducing the need for future 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 to be from mould induced asthma, then the amount of $542 million dollars is saved in Canada by removing 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 attacks which 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 above is an approximate (conservative) burden of $3.1 billion dollars a year in the US health care system for treating mould affected asthmatics which can be eliminated with the pre-emptive remediation of US homes with asthmatic occupants that are IAQ mould affected. At an upper average cost of $ 5000 to remediate a home, this can translate into the remediation of over 600,000 homes a year.

A positive net present value of the measured reduction in future medical costs forms the basis for a significant shift in how the medical system might address mould affected patients by changing from reactive to taking proactive measures as the pressure to reduce health care dollars mounts. 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 care system is to use statistically relevant information from site assessments conducted by researchers.

Howden-Chapman (2007) found that by insulating homes in New Zealand, whereby reducing heat loss and moisture development within the home, incidents of ill-health and correspondingly work sick leave and hospital visits dropped significantly. Hospital admissions for 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 half the odds (54%) of having a day off school compared with the control group while adults had a 39% reduction in lost work days due to respiratory symptoms. Low vitality is a trademark response to SBS and mould affected environments. This study showed a drop in low vitality complaints from 445 of 967 respondents (46%) to 290 of 967 (30%) respondents after remediation of their homes, a 35% drop. Alternately, the happiness scale tipped upwards by 49%.
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Kercsmar (2006) showed a significant reduction in symptom days and health care support for asthmatic children who lived in damp mould affected homes that were subsequently remediated of mould and moisture sources. Subsequent review of the post remediation portion of the study indicates that the rate of asthmatic impact was reduced from 33% of the remediation control group to only 3.4%, a 90% reduction rate. The study connects damp environments to mould growth and to the significant increase in incidents of asthma and other respiratory symptoms in our North American population. Symptoms are noted as disproportionately high in the 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 followed to its logical conclusion with all aspects of it valued and incorporated into the decision process to ensure a full cycle approach is taken towards a fully sustainable solution. This includes ensuring all impacts are tallied, including hard costs; such as, emergency room visits and bed nights, drugs and 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 the measure 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 quick downward spiral towards chronic financial and corresponding mental stress which David Shipler described 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 a call 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 unreliable used car, which jeopardizes a mother's punctuality at work, which limits her promotions and earning capacity, which confines her to poor housing."

Interestingly, Shipler describes the externalities of ill-health although he was sharing the perspective of limited choice for those who are poor. But the fact remains, they are inexplicably connected. The cost in human potential is immense and difficult to measure. The tangible costs Page 14 of 25

of the hospital and doctor visits and dispensation of drugs can start to form the basis for a cost benefit analysis and be conservative as the real cost includes that and more if one was to add the impact 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 anchored health care model that verifies societal gains along with occupant health gains in the process of ridding 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 societal impact by not addressing mould environments in built structures. These studies expose a significant drop in productivity and increase in absenteeism that is due directly to SBS-like conditions (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 in buildings exceeds the cost of heating those buildings (Seppanen 1999) and measures to improve IAQ 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 factors such 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 homes remediated.

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The measured expense to employers was reduced by $9,200 per employee per year (Geotzel 2001) for better indoor air quality with a direct health component of $4,700; turnover component of $3,700 and $800 for 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 savings overall 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 that would be in worker efficiency increase and absenteeism decrease; but overall, it appears that the employer can benefit by upgrading their office space not only with a lower turnover and sick leave rate, they can also benefit financially by achieving a high rate of return on capital investment from the productivity savings and increased revenues from healthier and happier workers.

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 two LEEDS buildings, one silver and one platinum, in three major steps: one, determine the incremental first costs for the increased IEQ (indoor environment quality); two, then measure the incremental change in occupant well-being and productivity through survey; then three, establish the life cycle cost benefits. The research results confirm significant life cycle cost benefits that indicate LEED buildings can be economically viable investments. The report variables were limited to the economic performance to occupant well-being and productivity and excluded the other IEQ elements included in LEED (energy; operations and maintenance; product lifecycles; employee turnover rates (which provide a positive net benefit per Geotzel (2001); liability relates costs, etc).

Reviewing LEED buildings for ramifications towards instituting capital expenditures to proactively 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 in construction. The heating, ventilation, and filtration systems are far more superior in commercial buildings, leading to conservative results when applied to residential environments. Residential environments 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 in commercial buildings. Further, the costs to construct and remediate commercial buildings are more than double that of typical residences due in part to higher quality products and systems required. The LEED research results therefore are expected to be conservative when compared to residential environment.

The research results from Syal (2009) are significant in that the benefits far outweighed the initial 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 reduced absenteeism for asthma/ respiratory allergies/ depression/ stress and higher productivity of over 2% totalled to a little over $ 1,000 per affected person per year (97% of which was measured from productivity gains). One building had a total population of 56, another building had 207. Of the 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 $250,694 respectively 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 end of occupant history with asthma (35 %), $ 3,400 per affected worker. Further by dissecting the results down to the mould affected using Jaakkolas 35.1% effects ratio, the mould affected causes an impact of $3,400 x .351 or almost $ 1,200 to the economy per year when affected commercial environments are not remediated.

Further, the life cycle cost analysis for the two buildings was conducted using a benefit cost analysis 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 which dropped to 21 for a SP of 15 years and rose to 44 with an IR increase to 6% from 3%. For the base scenario, the investment had a 7 month payback period with a rate of return of 167%. The larger building provided a B/C of 10 which decreased to 7 for a 15 year SP and increased to 14 for an IR of 6%. For the base scenario, the investment had a 2 year payback period with a rate of return of 50%. Other LCCA studies provided a wide range of ratios ( 15-16 Kats (2003), 1-2 SBW (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 mould affected 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 a significant financial as well as social impact on society, in the form of a critical load on the health care system an increased impact on family and the overall social fabric of society and loss of productivity in the workplace as well as an overall adverse impact on business conditions in North 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 calculated to be $3.6 billion dollars a year. The net cost benefit to the health care system alone for removing toxic moulds from homes has been calculated to be in excess of $ 145,000 per affected person over their lifetime (based on a 20 year period). The real cost to society is in the hundreds of billions of dollars per year when the issue is expanded to include commercial, financial, and social based impacts. This paper recommends further investigation into solutions to correct this societal level crisis are critical to the well-being of families, community, and the North American economy at large.

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

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

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

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The focus of this paper exposes the impact of this disconnect and provides a cost-benefit approach (model) to proactively address the problem of ill-health in homes due to toxic mould environments. The cost-benefit to remedy damp environments against mould growth is measured against 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 of Health to undertake proactive remediation programs in homes that are known to be the source of toxic mould that aggravates occupants who then seek health care solutions. By enacting this model, the participating Health Authorities not only become an integral part of a sustainable solution to ill-health due to mould ingestion, they reduce its effects on the cost of health care with a significant net financial benefit.

The real cost of not addressing toxic mould in homes must include externalities such as general loss of well-being, increased mental health issues, the increased emotional impact on self and 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 with recommendations that changes in built structure design and maintenance be undertaken through a broad 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 significantly affects the function of occupants that is both practical and sustainable. Add in the impacts on business 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 simple mission.

Acknowledgements

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

Limitations
A thorough review of literature found the scientific extension of the subject matter sparse and somewhat limited. Motivation for research came from personal experience in the IAQ Page 19 of 25

residential field over the past 8 years that exposed a lack of science based facts and limited research. The literature search as well as personal experience in the form of networking and professional communication provided the basis for determining the present IAQ residential conditions and issues. Economic results as well as medical based results are also drawn from commercial building and multi-family environments and inner-city studies with study results assumed to be consistent with single family dwelling environments. Further study is necessary to prove the accuracy of this assumption.

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Wikipedia (2011) En.wikipedia.org/wiki/Odds_ratio .. /rate_ratio .. /incidence_rate

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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 or mold and new-onset asthma or new-onset asthma-like symptoms that use odds ratios as a measure of risk Table 3-2: Epidemiological studies investigating an association between indoor dampness or mold 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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