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Study of the different Cutoff Point of the QEESI Questionnaire as a Screening Tool for Sick Building Syndrome Diagnosis in Taiwan

Study of the different Cutoff Point of the QEESI Questionnaire as a Screening Tool for Sick... The Indoor Air Quality Management Act in Taiwan formally came into effect in November 2012 to protect public health. Studies have reported that public and private buildings in Taiwan currently have been facing 1), 2) pollution problems regarding indoor air quality (IAQ), which threatens the health of occupants. To clarify the correlation between the indoor air environment and influences on human health by using an economical and efficient method, the United States, Japan, and other countries use screening tools first to understand the health effects on building occupants, and, subsequently, adopt appropriate examination methods once primary influential factors are identified. To enable the integration of research results from Taiwan with those from abroad, this study introduced the quick environmental exposure and sensitivity inventory (QEESI) questionnaire, which the United States, Japan, and other countries have implemented for many years. In this study, the applicability of the QEESI questionnaire in screening sick building syndrome (SBS) in Taiwan was examined by observing the association between the QEESI score and IAQ survey results. The results from Taiwan were compared with those from the United States and Japan. A questionnaire concerning personal and residential environmental factors was also incorporated to identify factors with significant predictive power for the QEESI score. The following conclusions were derived from this study. 1. The correlation between the IAQ survey values and the QEESI score indicates the capability of the QEESI questionnaire to identify problems related to sick buildings and to serve as a screening tool for SBS in Taiwan. 3-5) 2. Currently, using the cutoff points proposed by Japanese researchers to judge the QEESI score can optimally enhance the correlation between the IAQ survey results and the QEESI scores for people in Taiwan. 3. Eight factors with significant predictively power for the QEESI score include gender, age, an understanding of the mechanism of SBS occurrence, allergy history, building type, air ventilation, the use of deodorants and fragrances, and smoking. These factors can serve as key points when performing on-site examinations. Keywords: QEESI questionnaire; SBS diagnosis; QEESI score; Cutoff Point; concentration in air 1. Introduction facing pollution problems regarding indoor air quality 1), 2) The Indoor Air Quality Management Act in Taiwan (IAQ), which threatens the health of occupants. came into effect in November 2012 to protect public Clarifying the correlation between indoor air health. In addition, studies have reported that public environments and influences on human health and private buildings in Taiwan currently have been requires precise IAQ tests; however, implementing comprehensive testing is time consuming and highly expensive. By using screening tools first to understand *Contact Author: Lin-lin Huang, Ph.D., Assistant Professor, health effects on building occupants and subsequently Department of Architecture and Interior Design, adopting appropriate examination methods once Cheng Shiu University, Taiwan key influential factors are identified, improvement Tel: +886-911-278685 Fax: +886-7-555-3577 countermeasures can be determined economically and E-mail: lin8612@gmail.com efficiently. ( Received April 15, 2013 ; accepted February 26, 2014 ) Journal of Asian Architecture and Building Engineering/May 2014/513 507 To enable the integration of research results obtained identify factors with significant predictive power for in Taiwan with those reported in international studies, the QEESI score. These predictors, which included this study introduced the quick environmental exposure significant environmental factors that affect human and sensitivity inventory (QEESI) questionnaire, which health, can serve as key points when conducting on- the United States, Japan, and other countries have site examinations. 3-7) implemented for several years. The content design The following sections describe the results obtained of the QEESI questionnaire is stable, and the Chinese during the third and fourth stages of this study. 8) version has passed reliability and validity tests. In this study, the applicability of the QEESI 3. Research Methodology questionnaire in screening sick buildings in Taiwan 3.1 Questionnaire Survey was examined by observing the correlation between the 3.1.1 Distribution and Recovery of the Questionnaires QEESI score and IAQ survey results. A questionnaire An anonymous survey was conducted after the concerning personal and residential environmental researchers received training from the Institutional factors was also incorporated to identify factors with Review Board because of ethical considerations. The significant predictive power for the QEESI score. questionnaire survey had the following characteristics: These factors provide key points when performing on- 1. Time of survey: The survey was administered site investigations. from November 2008 to December 2008. In addition, the QEESI questionnaire can be used 2. Survey participants: Because the study in national surveys, in which the results can become questionnaire contained six pages, purposive crucial references in fields related to architectural sampling was adopted to prevent people who could research and for policymaking regarding national not understand the survey topics and items from health insurance programs. participating in the survey and influencing the results. The study researchers were assisted by colleges, public 2. Research Design and private offices, and interior decoration companies During the first stage of this study, a nationwide or relevant vendors to obtain consent from the survey anonymous survey containing the QEESI questionnaire participants. Subsequently, methods for completing the (Chinese version) and a questionnaire on personal and questionnaire were explained to the participants. residential environmental factors were conducted. Eight- 3. Methods of questionnaire distribution and hundred and fifty questionnaires were distributed and recovery: To enhance the valid questionnaire recovery 678 questionnaires were returned (resulting in a response rate, questionnaire distribution and recovery was ratio of 80%). After excluding the invalid answers, conducted through personal visits (as often as possible). namely answers that were incomplete for one or more When this method was unfeasible, questionnaires were questions, the number of valid questionnaires was 658 sent and returned through registered mail. Regarding (resulting in an effective response ratio of 77%). the public and private sectors, relevant contact persons During the second stage, IAQ surveys of residences were commissioned to explain, distribute, and collect and on-site interviews were conducted. Of the 658 the questionnaires. people who returned valid questionnaires during the 3.1.2 Questionnaires first stage, those who expressed that they were "willing Two types of questionnaire were used. One was to cooperate with an IAQ test" were considered used to collect information concerning the occupants possible interviewees. From these samples, the study and their living environments. (Table 1.) The other selected 65 people from 40 households who, at the was the QEESI questionnaire (Chinese version, Table time the survey was conducted, lived in a new or Table 1. Survey Items Concerning Volunteers and Their Living newly renovated (within 5 years) building in Tainan or Conditions Kaohsiung City, where the weather is hot and humid Survey Items Survey Details throughout the year, to participate in the interview. The (Number of 2) results of the IAQ survey have been published. Questions) Personal Information Gender, age, allergy history, Du ri n g t h e t h i rd st a g e o f t h e st u dy, t he 6 5 (7) family history, time spent in the participants were categorized based on their QEESI home, understanding SBS scores by using cutoff points established in the United Information on the Building style, construction States, Japan, and Taiwan. The correlations between Residential Building year, number of stories, reasons (6) for renovation, floor area, floor the IAQ survey values and the QEESI scores were materials, ventilation system, and simultaneously examined to verify the applicability of so forth the QEESI questionnaire for use as a screening tool Indoor Number and type of pets; use in diagnosing sick buildings in Taiwan. Moreover, the Environmental of insecticides, aromatics and/ current optimal cutoff points for the QEESI score as Conditions and or incense; amount of tobacco Living Style (6) smoked used in Taiwan were identified. Surrounding Outdoor Types of sites surrounding the Finally, during the fourth stage, using the 658 valid Environments surveyed house questionnaires, statistical methods were adopted to (2) 508 JAABE vol.13 no.2 May 2014 Lin-lin Huang Table 2. Contents of the QEESI Form 3.3 Methods for Classifying QEESI Scores Based on Question # Scale of the Items Related to the Different Cutoff Points Symptoms Symptoms (1) English version: Effective subscales and cutoff Q.1 Chemical Inhalant Tobacco smoke, points for diagnosing SBS in citizens of the United Intolerance Scale insecticides, paints, States were the "Chemical Inhalant Intolerance Scale", thinner (Q1): with a cutoff point of 40 points; "Symptom Q 2 Other Intolerance Food additives, Severity Scale" (Q3): with a cutoff point of 40 points; Scale caffeine, alcohol, and: "Masking Index" (Q4) : with a cutoff point of 4 pollen, and other substances points. Q.3 Symptom Severity Muscles, ligament, Furthermore, the QEESI scores can be used to Scale conjunctiva, mucous evaluate a person's risk of SBS or multiple chemical membrane, head, skin sensitivity (MCS), which is classified into four stages Q.4 Masking Index Smoking, drinking, of " Very Suggestive" , "S omewhat Sugges tive" , stimulus foods, "Not Suggestive" and "Problematic". Symptom perfumes, and other Severity Scale (Q3): is the primary indicator for this substances classification (Table 4.). Q.5 Life Impact Scale Meals, work, study, family relations, house (2) Japanese version: The effective subscales and keeping cutoff points for diagnosing SBS in Japanese citizens were the Chemical Inhalant Intolerance Scale (Q1), 2.), which comprises five subscales, with 10 questions with a cutoff point of 40 points. Symptom Severity in each subscale, constituting a total of 50 questions. Scale (Q3), with a cutoff point of 20 points; and: Life Among these subscales only Subscale 4, "masking," Impact Scale (Q5), with a cutoff point of 10 points. can be answered with "yes" or "no," which receive Moreover, based on QEESI scores, a person's risk of a score of one and zero, respectively. Other subscale SBS or MCS could be categorized into three stages of answers were scored from zero to 10 (zero: unaffected, "probable," "vulnerable," and "healthy". (Table 5.) five: medium, 10: severely affected). The assessment is based on a score ranging from zero to 100. Table 4. Screening and Categorization Benchmarks for SBS/ 6,7) MCS Based on the QEESI Questionnaire (English Version) The original English version, translated Japanese 3-5) 8) Category Q3 Q1 Q4 version, and traditional Chinese version (used in Very Suggestive ≧ 40 ≧ 40 ≧ 4 this study) of the QEESI passed reliability and validity Very Suggestive ≧ 40 ≧ 40 < 4 tests, indicating that the questionnaires possessed a Somewhat precise design, complete structure, and applicability to 40 < 40 4 ≧ ≧ Suggestive diverse environments and populations. Nevertheless, Not Suggestive 40 < 40 < 4 the questionnaires were distributed to people from Problematic < 40 ≧ 40 ≧ 4 different groups, who demonstrated differences in Problematic < 40 ≧ 40 < 4 external living environments, internal culture and Not Suggestive < 40 < 40 4 habits, and ethnicity. Consequently, varying subscales Not Suggestive < 40 < 40 < 4 and cutoff p Consequently, varying subscales and cutoff points for effectively diagnosing SBS were Table 5. Screening and Categorization Benchmarks for SBS/ MCS Based on the QEESI Questionnaire (Japanese Version) generated for the three versions of the QEESI questionnaire based on local residents. The differences Category Q1 Q3 Q5 in the subscales and cutoff points are listed in. (Table 3.) 40 20 10 ≧ ≧ ≧ 40 20 10 8) ≧ ≧ ＜ Table 3. Cutoff Points Probable ＜ 40 ≧ 20 ≧ 10 Subscale Country Q1 Q2 Q3 Q4 Q5 ≧ 40 ＜ 20 ≧ 10 USA 40 × 40 4 × Vulnerable ≧ 40 ＜ 20 ＜ 10 Japan 40 × 20 × 10 Healthy 20 10 10 ＜ ＜ ＜ Taiwan × 25 21 × 13 (3) Chinese version: Currently, no medical doctor 3.2 Identifying the Predictive Power of Personal and researching SBS is available in Taiwan, and the Residential Environment Information regarding the QEESI questionnaire is still in the experimental stages. Chinese QEESI Questionnaire Score However, because this study focused on the correlation An independent samples test and a one way analysis between the QEESI score and the concentration of of variance (ANOVA) were used to examine differences indoor hazardous substances in the air, the standards in the QEESI (including Q1, Q2, Q3, and Q5) for for the Chinese version of the QEESI questionnaire interviewees exhibiting diverse attributes (i.e., four were also incorporated for cross-country comparisons. variables: the resident, residence, indoor environment, The questionnaire and the classification of groups or and surrounding environment). If the F test results of the categories is based on three subscale cutoff points. The one-way ANOVA reached a level of significance (α = method for categorizing groups is described as follows: 0.05), a Scheffé's posthoc comparison was performed. JAABE vol.13 no.2 May 2014 509 None: None of the scores for the three subscales 4. Survey Results exceed the cutoff points. That is, Q2 <25 points, Q3 4.1 Pred ictive C ap ab ility of Pers onal an d <21 points, and Q5 < 13 points. Residential Environmental Factors for the QEESI One: One of the scores among the three subscales (Chinese Version) Score exceeds the cutoff point. For example, Q2 > 25 points, Based on the data collected from the 658 valid Q3 > 21 points, or Q5 > 13 points. questionnaires, multiple regression analysis was Two: Two of the scores among the three subscales performed, with personal and residential environmental exceed the cutoff points. For example: Q2 >25 points factors as the independent variables, and the individual and Q3 >21 points, or Q2 >25 points and Q5 >13 scores for the QEESI subscales as the dependent points. variables. In this study, eight items were determined to Three: All the scores of the three subscales all significantly predict the QEESI (Chinese version) score exceed their corresponding cutoff points. That is,Q2 of the user, as described as follows. The personnel who >25 points, Q3 >21 points, and Q5 >13 points. This provide SBS diagnosis services can focus on these group contains people who have the highest QEESI items during on-site examinations to improve work scores. (Table 6.) efficiency. (Table 8.) (1) Resident Attributes: Table 6. Screening and Categorization Benchmarks for SBS/ a. Gender was a significant predictor of: "Other MCS Based on the QEESI Questionnaire (Chinese Version) Intolerance Scale" (Q2) and "Symptom Severity Category Q2 Q3 Q5 Scale "(Q3): The scores of the female participants None <25 <21 <13 were higher than those of the male participants, and <13 ≧ 25 <21 the results were the same as the results of research <13 One <25 21 conducted in Japan. <25 <21 ≧ 13 b. Age: Age < 20 years was a significant predictor of <13 ≧ 25 ≧ 21 "Other Intolerance Scale". (Q2) Two <25 21 ≧ c. Understanding of the mechanism of SBS occurrence ≧ 25 <21 ≧ 21 significantly predicted "Life Impact Scale". (Q5) Three ≧ 25 ≧ 21 ≧ 21 d. Allergy history was a significant predictor of 3.4 Observations of QEESI Categories and IAQ "Other Intolerance Scale". (Q2) : "Symptom Severity Survey Values Scale" (Q3), and "Life Impact Scale" (Q5). The scores Because the survey targets were residences that were of participants with a history of allergies were higher in use, and 40 out of 65 residences were surveyed, one than those of people without allergies, which is in residence could contain more than one representative accordance with the results of research conducted in who answered the questionnaire. However, only the Japan. highest QEESI score obtained within a residence was (2) Residence Characteristics: used for grouping and classification. For example a. Building type could significantly predict Chemical (English version), for a residence comprising four Inhalant Intolerance Scale (Q1) and: Life Impact Scale residents, if one resident was grouped as N (not (Q5). suggestive), two were P (problematic), and the other b. Air ventilation was a significant predictor of was V (very suggestive), the residence would be Chemical Inhalant Intolerance Scale (Q1). considered group "V." (Table 7.) (3) Indoor Environment: a. The use of deodorants and fragrances was a Table 7. Classification of the Residences by Each Cutoff Point significant predictor of "Symptom Severity Scale" (Q3). Cutoff point USA JP TW b. The use of tobacco significantly predicted Not Resident 1 Healthy None "Chemical Inhalant Intolerance" Scale" (Q1). The suggestive scores of nonsmokers were higher than those of Resident 2 Problematic Vulnerable One smokers, which was the same as the results of research Resident 3 Problematic Vulnerable Two Very conducted in Japan. Resident 4 Probable Three suggestive (4) Surrounding Environment: Overall Very None of the factors for surrounding environments Classification Probable Three suggestive were significantly predictive of any of the subscales of the residents in the Chinese version of the QEESI questionnaire, After categorizing the 65 participants based on their suggesting that different residential surroundings did QEESI scores, their residences were then classified not significantly influence the QEESI score of the into respective categories. Subsequently, the mean IAQ respondents. A reason for this tendency could be that concentration for each group (N, P, S, and V were used the study participants lived in areas (regardless of as the x axis) was graphed using a trend line to observe whether these areas were urban or rural) under similar the relationship between the QEESI scores and the air pollution conditions, or that, for most of the study concentration of indoor air pollutants. respondents, the indoor air pollution in their residence 510 JAABE vol.13 no.2 May 2014 Residence Indoor Characteristics Environment Resident Attributes Table 8. Predictive Capability of Personal and Residential Environmental Factors for the QEESI Score Q1 Q2 Q3 Information on the Personal & Q5 Chemical Inhalant Other Intolerance Symptom Severity Residential Building Life Impact Scale Intolerance Scale Scale Scale Gender; male -2.09 -3.32** -3.99* -0.87 (female : referenced) Age: (>50 : referenced) <20 -9.10 -9.20* -6.24 -5.07 Understanding of SBS -2.55 -3.28 -2.91 -4.32* yes (no= referenced) allergy history : 0.78 4.95*** 6.93*** 6.24*** yes (no= referenced Building type : target house -4.45** 0.22 -2.31 -2.83* (apartment= referenced) ventilation system : natural -3.76* -0.99 0.09 -0.63 (air conditioner= referenced) Aromatics : yes 1.27 2.32 3.33* 2.39 (no= referenced) smoking : yes (no= referenced) -4.93* 1.01 -1.65 -1.32 R 8% 10% 9% 12% *p < .05, **p < .01, ***p < .001 was caused mainly by indoor factors. Specifically, concentration of hazardous substances HCHO and the indoor/outdoor (I/O) ratio was greater than 1. TVOC at 39/49 and 376/430 (µg/m ), respectively. No These statistical results do not imply that outdoor air residence (0%) exceeded the standard for HCHO, and quality should be disregarded. Instead, to accurately one (33%) exceeded that of TVOC. identify environmental factors that affect the health of Eight residences (20%) were categorized into the residents, the outdoor air quality should be measured "Somewhat Suggestive" group, with the mean/maximal during IAQ testing and the I/O ratio should be obtained concentration of hazardous substances HCHO and to identify the sources of pollution correctly. TVOC at 55/107 and 331/684 (µg/m ), respectively. 4.2 The Correlation Between the QEESI Score One (12.5%) residence exceeded the standard for Categories and IAQ Survey Values HCHO, and two (25%) exceeded that for TVOC. This study adopted the following standards for Eleven residences (28%) were categorized into measuring IAQ: formaldehyde (HCHO) concentrations group "Very Suggestive", with the mean/ maximal of 100µg/m (Ministry of Health, Labour and Welfare, concentration of hazardous substances HCHO and Japan; Environmental Protection Administration, TVOC at 55/143 and 374/843 (µg/m ), respectively. Taiwan) and a total volatile organic compound (TVOC) One (9%) residence exceeded the standard for HCHO, concentration of 400µg/m (temporary standard; and four (36%) exceeded that of TVOC. Ministry of Health, Labour and Welfare, Japan). B a r c h a r t s o f t h e t e st e d T VOC a n d HC HO The researchers used statistical figures to depict the concentrations for the four QEESI groups suggested test concentration values in the four QEESI groups that the QEESI scores increased as the TVOC and observe whether the concentration of indoor concentration increased, and this upward trend was air pollutants increased as the group increase. (N more obvious than that for the HCHO concentration. = Not Suggestive, S = Somewhat Suggestive, P = The R values for the TVOC and HCHO trend lines Problematic, V= Very Suggestive, N<P <S<V). were 0.44 and 0.63, respectively (Figs.2. and 3.). 4.2.1 Classification Using the Cutoff Points Established in the United States Among the 40 study residences, 18 residences (45%) were categorized as the "Not Suggestive" group (Fig.1.). Regarding the concentration of hazardous substances (µg/m ), the mean/maximal values of HCHO and TVOC were 44/135 and 284/599, respectively. One (5.5%) residence exceeded the standard for Fig.1. Classification of the 40 Study Residences Using the U.S. HCHO, and three (16.7%) exceeded that for TVOC. Cutoff Points Three residences (7%) were categorized into (N=Not Suggestive, S=Somewhat Suggestive, the "Problematic" group, with the mean/maximal P= Problematic, V= Very Suggestive) JAABE vol.13 no.2 May 2014 511 B a r c h a r t s o f t h e t e st e d HC HO a n d T VOC concentrations based on the three QEESI groups showed that the QEESI scores increased as both the HCHO and TVOC concentrations increased. These results were more obvious than the results determined using the USA cutoff points for classification. The R values for the TVOC and HCHO trend lines were 0.99 and 0.86, respectively (Figs.5. and 6.) Fig.2. Average TVOC Concentration Distribution for Each QEESI Group Based on the U.S. Cutoff Points among the 40 Study Residences Fig.5. Average TVOC Concentration Distribution for Each QEESI Group Based on the Japanese Cutoff Points Among the 40 Study Residences Fig.3. Average HCHO Concentration Distribution for Each QEESI Group Based on the U.S. Cutoff Points among the 40 Study Residences 4.2.2 Results of Using the Cutoff Points Established in Japan for Classification Three residences (7%) were categorized into the "Healthy" group. Regarding the concentration of hazardous substances observed in these residences (µg/ Fig.6. Average HCHO Concentration Distribution for Each m ), the mean/maximal concentration of HCHO and QEESI Group Based on the Japanese Cutoff Points Among the TVOC were 26/37 and 224/200, respectively. None 40 Study Residences (0%) of the residences exceeded the standards for 4.2.3 Results of Using the Cutoff Points Established HCHO or TVOC. in Taiwan for Classification Thirteen residences (33%) were in the "Vulnerable" Forty residences were analyzed in this study: group, with the mean/maximal concentration of Eight residences (20%) were categorized into hazardous substances HCHO and TVOC at 48/135 and the "None" group. Regarding the concentration of 298/599 (µg/m ), respectively. Two (15%) residences hazardous substances observed in these residences (µg/ exceeded the standard for HCHO, and three (23%) m ), the mean/maximal concentration of HCHO and exceeded that for TVOC. TVOC was 43/107 and 327/486, respectively. One Twenty four residences (60%) were in the "Probable" (12.5%) residence exceeded the standard for HCHO, group, with the mean/maximal concentration of and one (12.5%) exceeded that for TVOC. hazardous substances HCHO and TVOC at 52/143 Twelve residences (30%) were in the "One" group, and 352/842(µg/m ), respectively. One (4%) residence with the mean/maximal concentration of hazardous exceeded the standard for HCHO, and seven(29%) substances HCHO and TVOC at 55/144 and 327/599 exceeded that for TVOC (Fig.4.). (µg/m ), respectively. Two (15%) residences exceeded the standard for HCHO, and four (31%) exceeded that for TVOC. Eight residences (20%) were in group "Two", with the mean/max concentration of hazardous substances HCHO and TVOC as 53/95 and 393/842(µg/m ), respectively. No(0%) residence exceeded the standard for HCHO, whereas three (37.5%) exceeded that of TVOC. Fig.4. Categorization of the 40 Study Residences Using Twelve residences (30%) were in the "Three" group, Japanese Cutoff Points with the mean/maximal concentration of hazardous H=Healthy, V=Vulnerable, P=Probable 512 JAABE vol.13 no.2 May 2014 substances HCHO and TVOC at 51/144 and 336/544 Eight factors with significant predictively power for (µg/m ), respectively. One (8%) residence exceeded the QEESI score include gender, age, an understanding the standard of HCHO, and three (25%) exceeded that of the mechanism of SBS occurrence, allergy history, of TVOC (Fig.7.). building type, air ventilation, the use of deodorants and fragrances, and smoking. These factors can serve as key points when performing on-site examinations. Acknowledgments The chief author would like to express his appreciation to the families of the 40 research participants for their assistance and co-operation during the survey, and deep gratitude to the Department of Healthy Building and Housing of the National Institute Fi g .7 . Categorization of the 40 Study Residences Using of Public Health of Japan and the Taiwan Association Taiwanese Cutoff Points of Sick-Building Consultants. Without their funding, technical assistance such as providing samplers and analyzing data, and professional consultation, this research would have never been conducted. The chief author would also like to take this opportunity to thank all his friends, who have liberally contributed their time and efforts to help his finish this research. References 1) P. C. Wu et al. (2003) Rick assessment of formaldehyde in typical Fig.8. Average TVOC Concentration Distribution for Each office buildings in Taiwan. Indoor Air 2003 ; 13 : 1-5. QEESI Group Based on the Taiwanese Cutoff Points Among the 2) Lin-lin Huang et al. (2011) Field Survey on the Relation between 40 Study Residences IAQ and Occupants' Health in 40 Houses in Southern Taiwan. JAABE vol.10 no.1 May 2011, pp.249-256. B a r c h a r t s o f t h e t e st e d HC HO a n d T VOC 3) Sachiko Hojo et al. (2003) Application of Quick Exposure Sensitivity Inventory (QEESIC) for Japanese population : study concentrations based on the four QEESI groups of reliability and validity of the questionnaire. Toxicology and suggested that the QEESI scores increased as the Industrial Health 2003 ; 19 : 41-49. HCHO concentration increased, and this trend was 4) Sachiko Hojo et al. (2004) A case study on use of QEESI as a more obvious than that of the TVOC concentration. questionnaire for screening MCS/or sick building syndrome The R values for the TVOC and HCHO trend lines patients. Jpn J Clin Ecol (Vol.13 No.2), pp.110-119. 5) Sachiko Hojo et al. (2008) Clinical characteristics of physician- were 0.16 and 0.79, respectively (Figs.8. and 9.). diagnosed patients with multiple chemical sensitivity in Japan. International Journal of Hygiene and Environmental Health 211, pp.682-689. 6) Miller C.S., Prihoda T.J. (1999) The Environmental Exposure and Sensitivity Inventory (EESI). A standardized approach for measuring chemical intolerances, for research and clinical applications. Toxicology and Industrial Health 15 : 373-385. 7) Miller C.S., Prihoda T.J. (1999) Controlled comparison of symptoms and chemical intolerances reported by Gulf War veterans. Implant recipients and persons with multiple chemical sensitivity. Toxicology and Industrial Health 15 : 386-396. 8) Lin-lin Huang et al. (2011) The Preliminary Study of the Fig.9. Average HCHO Concentration Distribution for Each Applicability of QEESI Questionnaire as the Screening Tool of QEESI Group Based on the Taiwanese Cutoff Points Among the Sick Building Diagnosis in Taiwan, Journal of Architecture, No. 40 Study Residences 77, pp.63~88. (in Chinese) 9) Sachiko Hojo et al. (2008) Analysis of cut off-point and ongoing 5. Conclusion exposure to chemicals on the onset for Japanese multiple chemical sensitivity patients using QEESI©Jpn J Clin Ecol (Vol.17 No.2), The correlation between the IAQ survey values and pp.118-132. (in Japanese) the QEESI scores indicates the capability of the QEESI questionnaire to identify problems related to sick buildings and to serve as a screening tool for SBS in Taiwan. Currently, using the cutoff points proposed by Japanese researchers to judge the QEESI score can optimally enhance the correlation between the IAQ survey results and the QEESI scores for people in Taiwan. JAABE vol.13 no.2 May 2014 513 http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Asian Architecture and Building Engineering Taylor & Francis

Study of the different Cutoff Point of the QEESI Questionnaire as a Screening Tool for Sick Building Syndrome Diagnosis in Taiwan

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DOI
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Abstract

The Indoor Air Quality Management Act in Taiwan formally came into effect in November 2012 to protect public health. Studies have reported that public and private buildings in Taiwan currently have been facing 1), 2) pollution problems regarding indoor air quality (IAQ), which threatens the health of occupants. To clarify the correlation between the indoor air environment and influences on human health by using an economical and efficient method, the United States, Japan, and other countries use screening tools first to understand the health effects on building occupants, and, subsequently, adopt appropriate examination methods once primary influential factors are identified. To enable the integration of research results from Taiwan with those from abroad, this study introduced the quick environmental exposure and sensitivity inventory (QEESI) questionnaire, which the United States, Japan, and other countries have implemented for many years. In this study, the applicability of the QEESI questionnaire in screening sick building syndrome (SBS) in Taiwan was examined by observing the association between the QEESI score and IAQ survey results. The results from Taiwan were compared with those from the United States and Japan. A questionnaire concerning personal and residential environmental factors was also incorporated to identify factors with significant predictive power for the QEESI score. The following conclusions were derived from this study. 1. The correlation between the IAQ survey values and the QEESI score indicates the capability of the QEESI questionnaire to identify problems related to sick buildings and to serve as a screening tool for SBS in Taiwan. 3-5) 2. Currently, using the cutoff points proposed by Japanese researchers to judge the QEESI score can optimally enhance the correlation between the IAQ survey results and the QEESI scores for people in Taiwan. 3. Eight factors with significant predictively power for the QEESI score include gender, age, an understanding of the mechanism of SBS occurrence, allergy history, building type, air ventilation, the use of deodorants and fragrances, and smoking. These factors can serve as key points when performing on-site examinations. Keywords: QEESI questionnaire; SBS diagnosis; QEESI score; Cutoff Point; concentration in air 1. Introduction facing pollution problems regarding indoor air quality 1), 2) The Indoor Air Quality Management Act in Taiwan (IAQ), which threatens the health of occupants. came into effect in November 2012 to protect public Clarifying the correlation between indoor air health. In addition, studies have reported that public environments and influences on human health and private buildings in Taiwan currently have been requires precise IAQ tests; however, implementing comprehensive testing is time consuming and highly expensive. By using screening tools first to understand *Contact Author: Lin-lin Huang, Ph.D., Assistant Professor, health effects on building occupants and subsequently Department of Architecture and Interior Design, adopting appropriate examination methods once Cheng Shiu University, Taiwan key influential factors are identified, improvement Tel: +886-911-278685 Fax: +886-7-555-3577 countermeasures can be determined economically and E-mail: lin8612@gmail.com efficiently. ( Received April 15, 2013 ; accepted February 26, 2014 ) Journal of Asian Architecture and Building Engineering/May 2014/513 507 To enable the integration of research results obtained identify factors with significant predictive power for in Taiwan with those reported in international studies, the QEESI score. These predictors, which included this study introduced the quick environmental exposure significant environmental factors that affect human and sensitivity inventory (QEESI) questionnaire, which health, can serve as key points when conducting on- the United States, Japan, and other countries have site examinations. 3-7) implemented for several years. The content design The following sections describe the results obtained of the QEESI questionnaire is stable, and the Chinese during the third and fourth stages of this study. 8) version has passed reliability and validity tests. In this study, the applicability of the QEESI 3. Research Methodology questionnaire in screening sick buildings in Taiwan 3.1 Questionnaire Survey was examined by observing the correlation between the 3.1.1 Distribution and Recovery of the Questionnaires QEESI score and IAQ survey results. A questionnaire An anonymous survey was conducted after the concerning personal and residential environmental researchers received training from the Institutional factors was also incorporated to identify factors with Review Board because of ethical considerations. The significant predictive power for the QEESI score. questionnaire survey had the following characteristics: These factors provide key points when performing on- 1. Time of survey: The survey was administered site investigations. from November 2008 to December 2008. In addition, the QEESI questionnaire can be used 2. Survey participants: Because the study in national surveys, in which the results can become questionnaire contained six pages, purposive crucial references in fields related to architectural sampling was adopted to prevent people who could research and for policymaking regarding national not understand the survey topics and items from health insurance programs. participating in the survey and influencing the results. The study researchers were assisted by colleges, public 2. Research Design and private offices, and interior decoration companies During the first stage of this study, a nationwide or relevant vendors to obtain consent from the survey anonymous survey containing the QEESI questionnaire participants. Subsequently, methods for completing the (Chinese version) and a questionnaire on personal and questionnaire were explained to the participants. residential environmental factors were conducted. Eight- 3. Methods of questionnaire distribution and hundred and fifty questionnaires were distributed and recovery: To enhance the valid questionnaire recovery 678 questionnaires were returned (resulting in a response rate, questionnaire distribution and recovery was ratio of 80%). After excluding the invalid answers, conducted through personal visits (as often as possible). namely answers that were incomplete for one or more When this method was unfeasible, questionnaires were questions, the number of valid questionnaires was 658 sent and returned through registered mail. Regarding (resulting in an effective response ratio of 77%). the public and private sectors, relevant contact persons During the second stage, IAQ surveys of residences were commissioned to explain, distribute, and collect and on-site interviews were conducted. Of the 658 the questionnaires. people who returned valid questionnaires during the 3.1.2 Questionnaires first stage, those who expressed that they were "willing Two types of questionnaire were used. One was to cooperate with an IAQ test" were considered used to collect information concerning the occupants possible interviewees. From these samples, the study and their living environments. (Table 1.) The other selected 65 people from 40 households who, at the was the QEESI questionnaire (Chinese version, Table time the survey was conducted, lived in a new or Table 1. Survey Items Concerning Volunteers and Their Living newly renovated (within 5 years) building in Tainan or Conditions Kaohsiung City, where the weather is hot and humid Survey Items Survey Details throughout the year, to participate in the interview. The (Number of 2) results of the IAQ survey have been published. Questions) Personal Information Gender, age, allergy history, Du ri n g t h e t h i rd st a g e o f t h e st u dy, t he 6 5 (7) family history, time spent in the participants were categorized based on their QEESI home, understanding SBS scores by using cutoff points established in the United Information on the Building style, construction States, Japan, and Taiwan. The correlations between Residential Building year, number of stories, reasons (6) for renovation, floor area, floor the IAQ survey values and the QEESI scores were materials, ventilation system, and simultaneously examined to verify the applicability of so forth the QEESI questionnaire for use as a screening tool Indoor Number and type of pets; use in diagnosing sick buildings in Taiwan. Moreover, the Environmental of insecticides, aromatics and/ current optimal cutoff points for the QEESI score as Conditions and or incense; amount of tobacco Living Style (6) smoked used in Taiwan were identified. Surrounding Outdoor Types of sites surrounding the Finally, during the fourth stage, using the 658 valid Environments surveyed house questionnaires, statistical methods were adopted to (2) 508 JAABE vol.13 no.2 May 2014 Lin-lin Huang Table 2. Contents of the QEESI Form 3.3 Methods for Classifying QEESI Scores Based on Question # Scale of the Items Related to the Different Cutoff Points Symptoms Symptoms (1) English version: Effective subscales and cutoff Q.1 Chemical Inhalant Tobacco smoke, points for diagnosing SBS in citizens of the United Intolerance Scale insecticides, paints, States were the "Chemical Inhalant Intolerance Scale", thinner (Q1): with a cutoff point of 40 points; "Symptom Q 2 Other Intolerance Food additives, Severity Scale" (Q3): with a cutoff point of 40 points; Scale caffeine, alcohol, and: "Masking Index" (Q4) : with a cutoff point of 4 pollen, and other substances points. Q.3 Symptom Severity Muscles, ligament, Furthermore, the QEESI scores can be used to Scale conjunctiva, mucous evaluate a person's risk of SBS or multiple chemical membrane, head, skin sensitivity (MCS), which is classified into four stages Q.4 Masking Index Smoking, drinking, of " Very Suggestive" , "S omewhat Sugges tive" , stimulus foods, "Not Suggestive" and "Problematic". Symptom perfumes, and other Severity Scale (Q3): is the primary indicator for this substances classification (Table 4.). Q.5 Life Impact Scale Meals, work, study, family relations, house (2) Japanese version: The effective subscales and keeping cutoff points for diagnosing SBS in Japanese citizens were the Chemical Inhalant Intolerance Scale (Q1), 2.), which comprises five subscales, with 10 questions with a cutoff point of 40 points. Symptom Severity in each subscale, constituting a total of 50 questions. Scale (Q3), with a cutoff point of 20 points; and: Life Among these subscales only Subscale 4, "masking," Impact Scale (Q5), with a cutoff point of 10 points. can be answered with "yes" or "no," which receive Moreover, based on QEESI scores, a person's risk of a score of one and zero, respectively. Other subscale SBS or MCS could be categorized into three stages of answers were scored from zero to 10 (zero: unaffected, "probable," "vulnerable," and "healthy". (Table 5.) five: medium, 10: severely affected). The assessment is based on a score ranging from zero to 100. Table 4. Screening and Categorization Benchmarks for SBS/ 6,7) MCS Based on the QEESI Questionnaire (English Version) The original English version, translated Japanese 3-5) 8) Category Q3 Q1 Q4 version, and traditional Chinese version (used in Very Suggestive ≧ 40 ≧ 40 ≧ 4 this study) of the QEESI passed reliability and validity Very Suggestive ≧ 40 ≧ 40 < 4 tests, indicating that the questionnaires possessed a Somewhat precise design, complete structure, and applicability to 40 < 40 4 ≧ ≧ Suggestive diverse environments and populations. Nevertheless, Not Suggestive 40 < 40 < 4 the questionnaires were distributed to people from Problematic < 40 ≧ 40 ≧ 4 different groups, who demonstrated differences in Problematic < 40 ≧ 40 < 4 external living environments, internal culture and Not Suggestive < 40 < 40 4 habits, and ethnicity. Consequently, varying subscales Not Suggestive < 40 < 40 < 4 and cutoff p Consequently, varying subscales and cutoff points for effectively diagnosing SBS were Table 5. Screening and Categorization Benchmarks for SBS/ MCS Based on the QEESI Questionnaire (Japanese Version) generated for the three versions of the QEESI questionnaire based on local residents. The differences Category Q1 Q3 Q5 in the subscales and cutoff points are listed in. (Table 3.) 40 20 10 ≧ ≧ ≧ 40 20 10 8) ≧ ≧ ＜ Table 3. Cutoff Points Probable ＜ 40 ≧ 20 ≧ 10 Subscale Country Q1 Q2 Q3 Q4 Q5 ≧ 40 ＜ 20 ≧ 10 USA 40 × 40 4 × Vulnerable ≧ 40 ＜ 20 ＜ 10 Japan 40 × 20 × 10 Healthy 20 10 10 ＜ ＜ ＜ Taiwan × 25 21 × 13 (3) Chinese version: Currently, no medical doctor 3.2 Identifying the Predictive Power of Personal and researching SBS is available in Taiwan, and the Residential Environment Information regarding the QEESI questionnaire is still in the experimental stages. Chinese QEESI Questionnaire Score However, because this study focused on the correlation An independent samples test and a one way analysis between the QEESI score and the concentration of of variance (ANOVA) were used to examine differences indoor hazardous substances in the air, the standards in the QEESI (including Q1, Q2, Q3, and Q5) for for the Chinese version of the QEESI questionnaire interviewees exhibiting diverse attributes (i.e., four were also incorporated for cross-country comparisons. variables: the resident, residence, indoor environment, The questionnaire and the classification of groups or and surrounding environment). If the F test results of the categories is based on three subscale cutoff points. The one-way ANOVA reached a level of significance (α = method for categorizing groups is described as follows: 0.05), a Scheffé's posthoc comparison was performed. JAABE vol.13 no.2 May 2014 509 None: None of the scores for the three subscales 4. Survey Results exceed the cutoff points. That is, Q2 <25 points, Q3 4.1 Pred ictive C ap ab ility of Pers onal an d <21 points, and Q5 < 13 points. Residential Environmental Factors for the QEESI One: One of the scores among the three subscales (Chinese Version) Score exceeds the cutoff point. For example, Q2 > 25 points, Based on the data collected from the 658 valid Q3 > 21 points, or Q5 > 13 points. questionnaires, multiple regression analysis was Two: Two of the scores among the three subscales performed, with personal and residential environmental exceed the cutoff points. For example: Q2 >25 points factors as the independent variables, and the individual and Q3 >21 points, or Q2 >25 points and Q5 >13 scores for the QEESI subscales as the dependent points. variables. In this study, eight items were determined to Three: All the scores of the three subscales all significantly predict the QEESI (Chinese version) score exceed their corresponding cutoff points. That is,Q2 of the user, as described as follows. The personnel who >25 points, Q3 >21 points, and Q5 >13 points. This provide SBS diagnosis services can focus on these group contains people who have the highest QEESI items during on-site examinations to improve work scores. (Table 6.) efficiency. (Table 8.) (1) Resident Attributes: Table 6. Screening and Categorization Benchmarks for SBS/ a. Gender was a significant predictor of: "Other MCS Based on the QEESI Questionnaire (Chinese Version) Intolerance Scale" (Q2) and "Symptom Severity Category Q2 Q3 Q5 Scale "(Q3): The scores of the female participants None <25 <21 <13 were higher than those of the male participants, and <13 ≧ 25 <21 the results were the same as the results of research <13 One <25 21 conducted in Japan. <25 <21 ≧ 13 b. Age: Age < 20 years was a significant predictor of <13 ≧ 25 ≧ 21 "Other Intolerance Scale". (Q2) Two <25 21 ≧ c. Understanding of the mechanism of SBS occurrence ≧ 25 <21 ≧ 21 significantly predicted "Life Impact Scale". (Q5) Three ≧ 25 ≧ 21 ≧ 21 d. Allergy history was a significant predictor of 3.4 Observations of QEESI Categories and IAQ "Other Intolerance Scale". (Q2) : "Symptom Severity Survey Values Scale" (Q3), and "Life Impact Scale" (Q5). The scores Because the survey targets were residences that were of participants with a history of allergies were higher in use, and 40 out of 65 residences were surveyed, one than those of people without allergies, which is in residence could contain more than one representative accordance with the results of research conducted in who answered the questionnaire. However, only the Japan. highest QEESI score obtained within a residence was (2) Residence Characteristics: used for grouping and classification. For example a. Building type could significantly predict Chemical (English version), for a residence comprising four Inhalant Intolerance Scale (Q1) and: Life Impact Scale residents, if one resident was grouped as N (not (Q5). suggestive), two were P (problematic), and the other b. Air ventilation was a significant predictor of was V (very suggestive), the residence would be Chemical Inhalant Intolerance Scale (Q1). considered group "V." (Table 7.) (3) Indoor Environment: a. The use of deodorants and fragrances was a Table 7. Classification of the Residences by Each Cutoff Point significant predictor of "Symptom Severity Scale" (Q3). Cutoff point USA JP TW b. The use of tobacco significantly predicted Not Resident 1 Healthy None "Chemical Inhalant Intolerance" Scale" (Q1). The suggestive scores of nonsmokers were higher than those of Resident 2 Problematic Vulnerable One smokers, which was the same as the results of research Resident 3 Problematic Vulnerable Two Very conducted in Japan. Resident 4 Probable Three suggestive (4) Surrounding Environment: Overall Very None of the factors for surrounding environments Classification Probable Three suggestive were significantly predictive of any of the subscales of the residents in the Chinese version of the QEESI questionnaire, After categorizing the 65 participants based on their suggesting that different residential surroundings did QEESI scores, their residences were then classified not significantly influence the QEESI score of the into respective categories. Subsequently, the mean IAQ respondents. A reason for this tendency could be that concentration for each group (N, P, S, and V were used the study participants lived in areas (regardless of as the x axis) was graphed using a trend line to observe whether these areas were urban or rural) under similar the relationship between the QEESI scores and the air pollution conditions, or that, for most of the study concentration of indoor air pollutants. respondents, the indoor air pollution in their residence 510 JAABE vol.13 no.2 May 2014 Residence Indoor Characteristics Environment Resident Attributes Table 8. Predictive Capability of Personal and Residential Environmental Factors for the QEESI Score Q1 Q2 Q3 Information on the Personal & Q5 Chemical Inhalant Other Intolerance Symptom Severity Residential Building Life Impact Scale Intolerance Scale Scale Scale Gender; male -2.09 -3.32** -3.99* -0.87 (female : referenced) Age: (>50 : referenced) <20 -9.10 -9.20* -6.24 -5.07 Understanding of SBS -2.55 -3.28 -2.91 -4.32* yes (no= referenced) allergy history : 0.78 4.95*** 6.93*** 6.24*** yes (no= referenced Building type : target house -4.45** 0.22 -2.31 -2.83* (apartment= referenced) ventilation system : natural -3.76* -0.99 0.09 -0.63 (air conditioner= referenced) Aromatics : yes 1.27 2.32 3.33* 2.39 (no= referenced) smoking : yes (no= referenced) -4.93* 1.01 -1.65 -1.32 R 8% 10% 9% 12% *p < .05, **p < .01, ***p < .001 was caused mainly by indoor factors. Specifically, concentration of hazardous substances HCHO and the indoor/outdoor (I/O) ratio was greater than 1. TVOC at 39/49 and 376/430 (µg/m ), respectively. No These statistical results do not imply that outdoor air residence (0%) exceeded the standard for HCHO, and quality should be disregarded. Instead, to accurately one (33%) exceeded that of TVOC. identify environmental factors that affect the health of Eight residences (20%) were categorized into the residents, the outdoor air quality should be measured "Somewhat Suggestive" group, with the mean/maximal during IAQ testing and the I/O ratio should be obtained concentration of hazardous substances HCHO and to identify the sources of pollution correctly. TVOC at 55/107 and 331/684 (µg/m ), respectively. 4.2 The Correlation Between the QEESI Score One (12.5%) residence exceeded the standard for Categories and IAQ Survey Values HCHO, and two (25%) exceeded that for TVOC. This study adopted the following standards for Eleven residences (28%) were categorized into measuring IAQ: formaldehyde (HCHO) concentrations group "Very Suggestive", with the mean/ maximal of 100µg/m (Ministry of Health, Labour and Welfare, concentration of hazardous substances HCHO and Japan; Environmental Protection Administration, TVOC at 55/143 and 374/843 (µg/m ), respectively. Taiwan) and a total volatile organic compound (TVOC) One (9%) residence exceeded the standard for HCHO, concentration of 400µg/m (temporary standard; and four (36%) exceeded that of TVOC. Ministry of Health, Labour and Welfare, Japan). B a r c h a r t s o f t h e t e st e d T VOC a n d HC HO The researchers used statistical figures to depict the concentrations for the four QEESI groups suggested test concentration values in the four QEESI groups that the QEESI scores increased as the TVOC and observe whether the concentration of indoor concentration increased, and this upward trend was air pollutants increased as the group increase. (N more obvious than that for the HCHO concentration. = Not Suggestive, S = Somewhat Suggestive, P = The R values for the TVOC and HCHO trend lines Problematic, V= Very Suggestive, N<P <S<V). were 0.44 and 0.63, respectively (Figs.2. and 3.). 4.2.1 Classification Using the Cutoff Points Established in the United States Among the 40 study residences, 18 residences (45%) were categorized as the "Not Suggestive" group (Fig.1.). Regarding the concentration of hazardous substances (µg/m ), the mean/maximal values of HCHO and TVOC were 44/135 and 284/599, respectively. One (5.5%) residence exceeded the standard for Fig.1. Classification of the 40 Study Residences Using the U.S. HCHO, and three (16.7%) exceeded that for TVOC. Cutoff Points Three residences (7%) were categorized into (N=Not Suggestive, S=Somewhat Suggestive, the "Problematic" group, with the mean/maximal P= Problematic, V= Very Suggestive) JAABE vol.13 no.2 May 2014 511 B a r c h a r t s o f t h e t e st e d HC HO a n d T VOC concentrations based on the three QEESI groups showed that the QEESI scores increased as both the HCHO and TVOC concentrations increased. These results were more obvious than the results determined using the USA cutoff points for classification. The R values for the TVOC and HCHO trend lines were 0.99 and 0.86, respectively (Figs.5. and 6.) Fig.2. Average TVOC Concentration Distribution for Each QEESI Group Based on the U.S. Cutoff Points among the 40 Study Residences Fig.5. Average TVOC Concentration Distribution for Each QEESI Group Based on the Japanese Cutoff Points Among the 40 Study Residences Fig.3. Average HCHO Concentration Distribution for Each QEESI Group Based on the U.S. Cutoff Points among the 40 Study Residences 4.2.2 Results of Using the Cutoff Points Established in Japan for Classification Three residences (7%) were categorized into the "Healthy" group. Regarding the concentration of hazardous substances observed in these residences (µg/ Fig.6. Average HCHO Concentration Distribution for Each m ), the mean/maximal concentration of HCHO and QEESI Group Based on the Japanese Cutoff Points Among the TVOC were 26/37 and 224/200, respectively. None 40 Study Residences (0%) of the residences exceeded the standards for 4.2.3 Results of Using the Cutoff Points Established HCHO or TVOC. in Taiwan for Classification Thirteen residences (33%) were in the "Vulnerable" Forty residences were analyzed in this study: group, with the mean/maximal concentration of Eight residences (20%) were categorized into hazardous substances HCHO and TVOC at 48/135 and the "None" group. Regarding the concentration of 298/599 (µg/m ), respectively. Two (15%) residences hazardous substances observed in these residences (µg/ exceeded the standard for HCHO, and three (23%) m ), the mean/maximal concentration of HCHO and exceeded that for TVOC. TVOC was 43/107 and 327/486, respectively. One Twenty four residences (60%) were in the "Probable" (12.5%) residence exceeded the standard for HCHO, group, with the mean/maximal concentration of and one (12.5%) exceeded that for TVOC. hazardous substances HCHO and TVOC at 52/143 Twelve residences (30%) were in the "One" group, and 352/842(µg/m ), respectively. One (4%) residence with the mean/maximal concentration of hazardous exceeded the standard for HCHO, and seven(29%) substances HCHO and TVOC at 55/144 and 327/599 exceeded that for TVOC (Fig.4.). (µg/m ), respectively. Two (15%) residences exceeded the standard for HCHO, and four (31%) exceeded that for TVOC. Eight residences (20%) were in group "Two", with the mean/max concentration of hazardous substances HCHO and TVOC as 53/95 and 393/842(µg/m ), respectively. No(0%) residence exceeded the standard for HCHO, whereas three (37.5%) exceeded that of TVOC. Fig.4. Categorization of the 40 Study Residences Using Twelve residences (30%) were in the "Three" group, Japanese Cutoff Points with the mean/maximal concentration of hazardous H=Healthy, V=Vulnerable, P=Probable 512 JAABE vol.13 no.2 May 2014 substances HCHO and TVOC at 51/144 and 336/544 Eight factors with significant predictively power for (µg/m ), respectively. One (8%) residence exceeded the QEESI score include gender, age, an understanding the standard of HCHO, and three (25%) exceeded that of the mechanism of SBS occurrence, allergy history, of TVOC (Fig.7.). building type, air ventilation, the use of deodorants and fragrances, and smoking. These factors can serve as key points when performing on-site examinations. Acknowledgments The chief author would like to express his appreciation to the families of the 40 research participants for their assistance and co-operation during the survey, and deep gratitude to the Department of Healthy Building and Housing of the National Institute Fi g .7 . Categorization of the 40 Study Residences Using of Public Health of Japan and the Taiwan Association Taiwanese Cutoff Points of Sick-Building Consultants. Without their funding, technical assistance such as providing samplers and analyzing data, and professional consultation, this research would have never been conducted. The chief author would also like to take this opportunity to thank all his friends, who have liberally contributed their time and efforts to help his finish this research. References 1) P. C. Wu et al. (2003) Rick assessment of formaldehyde in typical Fig.8. Average TVOC Concentration Distribution for Each office buildings in Taiwan. Indoor Air 2003 ; 13 : 1-5. QEESI Group Based on the Taiwanese Cutoff Points Among the 2) Lin-lin Huang et al. (2011) Field Survey on the Relation between 40 Study Residences IAQ and Occupants' Health in 40 Houses in Southern Taiwan. JAABE vol.10 no.1 May 2011, pp.249-256. B a r c h a r t s o f t h e t e st e d HC HO a n d T VOC 3) Sachiko Hojo et al. (2003) Application of Quick Exposure Sensitivity Inventory (QEESIC) for Japanese population : study concentrations based on the four QEESI groups of reliability and validity of the questionnaire. Toxicology and suggested that the QEESI scores increased as the Industrial Health 2003 ; 19 : 41-49. HCHO concentration increased, and this trend was 4) Sachiko Hojo et al. (2004) A case study on use of QEESI as a more obvious than that of the TVOC concentration. questionnaire for screening MCS/or sick building syndrome The R values for the TVOC and HCHO trend lines patients. Jpn J Clin Ecol (Vol.13 No.2), pp.110-119. 5) Sachiko Hojo et al. (2008) Clinical characteristics of physician- were 0.16 and 0.79, respectively (Figs.8. and 9.). diagnosed patients with multiple chemical sensitivity in Japan. International Journal of Hygiene and Environmental Health 211, pp.682-689. 6) Miller C.S., Prihoda T.J. (1999) The Environmental Exposure and Sensitivity Inventory (EESI). A standardized approach for measuring chemical intolerances, for research and clinical applications. Toxicology and Industrial Health 15 : 373-385. 7) Miller C.S., Prihoda T.J. (1999) Controlled comparison of symptoms and chemical intolerances reported by Gulf War veterans. Implant recipients and persons with multiple chemical sensitivity. Toxicology and Industrial Health 15 : 386-396. 8) Lin-lin Huang et al. (2011) The Preliminary Study of the Fig.9. Average HCHO Concentration Distribution for Each Applicability of QEESI Questionnaire as the Screening Tool of QEESI Group Based on the Taiwanese Cutoff Points Among the Sick Building Diagnosis in Taiwan, Journal of Architecture, No. 40 Study Residences 77, pp.63~88. (in Chinese) 9) Sachiko Hojo et al. (2008) Analysis of cut off-point and ongoing 5. Conclusion exposure to chemicals on the onset for Japanese multiple chemical sensitivity patients using QEESI©Jpn J Clin Ecol (Vol.17 No.2), The correlation between the IAQ survey values and pp.118-132. (in Japanese) the QEESI scores indicates the capability of the QEESI questionnaire to identify problems related to sick buildings and to serve as a screening tool for SBS in Taiwan. Currently, using the cutoff points proposed by Japanese researchers to judge the QEESI score can optimally enhance the correlation between the IAQ survey results and the QEESI scores for people in Taiwan. JAABE vol.13 no.2 May 2014 513

Journal

Journal of Asian Architecture and Building Engineering – Taylor & Francis

Published: May 1, 2014

Keywords: QEESI questionnaire; SBS diagnosis; QEESI score; Cutoff Point; concentration in air

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