University of Texas School of Medicine at San Antonio Is it the building, the occupant, or both? Using the QEESI© to investigate indoor air concerns. June 7, 2011 Indoor Air 2011 Tatjana Walker, RD, MPH; Thomas J. Prihoda, PhD; Claudia S. Miller, M.D., M.S. University of Texas School of Medicine at San Antonio Good morning. I’m Tatjana Walker. Today I’ll be speaking about how you can use a questionnaire to assist in resolving indoor air concerns. The title of our paper is, 的s it the building, the occupant, or both? Using the QEESI to investigate indoor air concerns. QEESI stands for: Quick Environmental Exposure and Sensitivity Inventory. It is a validated, published tool for assessing chemical intolerance, and it was developed by my coauthors, also from the UT School of Medicine at San Antonio, Dr. Thomas Prihoda and Dr. Claudia Miller. I’m delighted that Dr. Miller is here with us today and will available for questions after this presentation.

Chemical Intolerance About 5% of people report multiple chemical intolerances “Do you consider yourself sensitive to everyday chemicals like those in household cleaning supplies, paints, perfumes, soaps, garden sprays, or things like that?” (15%) We should begin by defining chemical intolerance. We prefer the term chemical intolerance to the other terms in use. Another common term, Multiple Chemical Sensitivity, is particularly problematic in the medical community, because the term sensitivity implies an immunologic sensitization involving IgE. Although a limited number of chemicals are sensitizing, in general the complaints of people with chemical intolerance are not related to allergic sensitization.

A New Theory of Disease— Toxicant-Induced Loss of Tolerance or “TILT” In fact, what Dr. Miller and her colleague Dr. Nicholas Ashford noted, is that chemical intolerances are just one facet of a larger underlying dynamic called TILT or Toxicant Induced Loss of Tolerance.

Evidence That We Are Dealing With a New Disease Mechanism Similar reports from more than a dozen countries—different languages, media YET they report similar new onset intolerances to structurally unrelated substances (foods, medications, alcoholic beverages, caffeine) and symptoms affecting multiple organ systems in response to these. This is what Kuhn called a “compelling anomaly”—observations that do not fit known theories of disease Compelling anomalies drive the search for new explanations, paradigms, theories

Common Indoor Conditions Linked to TILT (Stage 1) Remodeling—new carpets, glues, cleaners, and other VOC emitters Pesticides Mold Insufficient fresh make-up air

TOXICANT-INDUCED LOSS OF TOLERANCE ? Solvents Glues Paints Gasoline Nail polish/remover Indoor Air Volatile Organic Compounds (VOCs) New carpet Plasticizers Formaldehyde Fragrances Mold VOCs Drugs/Medical Devices Vaccines Anesthetics Implants Antibiotics Chemotherapy TOXICANT-INDUCED LOSS OF TOLERANCE ? Combustion-related Products Engine exhaust Tobacco smoke Oil well fire smoke Natural gas Tar/asphalt Cleaning Agents Phenolic disinfectants Ammonia Bleach Pesticides Organophosphates Carbamates, pyridostigmine Pentachlorophenol Pyrethrins

TOXICANT-INDUCED LOSS OF TOLERANCE ? Neuropsychological Attention Deficit Hyperactivity Disorder (ADHD) depression bipolar disorder panic disorder migraines and other headaches seizures autism Ear, Nose and Throat sinusitis polyps tinnitus recurrent otitis Cardiovascular arrhythmias hypertension hypotension Raynaud's phenomenon Miscellaneous Syndromes Chronic Fatigue Syndrome implant syndromes ''Gulf War Syndrome“ Post/other disaster syndromes Respiratory asthma Reactive Airways Dysfunction Syndrome (RADS) toluene dlisocyanate (TDI) hypersensitivity TOXICANT-INDUCED LOSS OF TOLERANCE ? Skin eczema hives other rashes, eruptions Gastrointestinal irritable bowel reflux Connective Tissue/Musculoskeletal fibromyalgia carpal tunnel syndrome temporomandibular joint dysfunction (TMJ) syndrome arthritis lupus and other auto-immune diseases

Identifying Toxicant-Induced Loss of Tolerance (TILT)?

The QEESI Validated, published questionnaire and screening tool 50 questions, self-administered 12-15 minutes to administer Research, clinical, building investigations Helps occupants understand their symptoms and intolerances

Available for download at: www.chemicalexposures.org

QEESI Symptom Star Pre- and Post-Exposure Before exposure event Since exposure event

QEESI Symptom Stars for 4 People in Sick Buildings Courtesy of Carl E. Grimes

How Can You Use This Information Without “Practicing Medicine”? Provide link to QEESI for occupants to self-administer Invite affected occupants to take the results to their doctors Some occupants will share the results with you, but don’t ask them to In either case, those affected will self-identify and will begin to understand that they may be especially susceptible These are the people who need accommodation Look for physicians you can work with—QEESI will help them understand too

Tatjana Walker, RD, MPH University of Texas School of Medicine at San Antonio walkert2@uthscsa.edu The QEESI is Available for Download at: www.chemicalexposures.org