Received Date : 23-Feb-2016

Accepted Article
Revised Date : 30-Jun-2016

Accepted Date : 31-Jul-2016

Article type : Original Article

Ventilation, Indoor Air Quality, and Health in Homes Undergoing Weatherization

P. W. Francisco,2 D.E. Jacobs,1,3 L. Targos,1 S. L. Dixon,3 J. Breysse,3 W. Rose,2 S. Cali1

1
University of Illinois at Chicago School of Public Health EOHS, 2121 W Taylor, Chicago IL

60612
2
University of Illinois at Urbana-Champaign Illinois, 1 E. Hazelwood Dr., Champaign, IL 61820
3
National Center for Healthy Housing, 10320 Little Patuxent Pkwy Suite 500, Columbia, MD

21044

Corresponding author: David E. Jacobs, dejacobsdc@gmail.com

The Institutional Review Board of the University of Illinois at Chicago reviewed and approved

this study, Protocol # 2011-0813.

Abbreviations:

ASHRAE – American Society of Heating Refrigeration and Air Conditioning Engineers

CFM – Cubic Feet per Minute

DOE – U.S. Department of Energy

HUD – US Department of Housing and Urban Development

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/ina.12325
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 WAP – U.S. DOE’s Wx Assistance Program
Accepted Article
Wx – Weatherization

ABSTRACT

Ventilation standards, health and indoor air quality have not been adequately examined for

residential weatherization. This randomized trial showed how ASHRAE 62-1989 (n=39 houses)

and ASHRAE 62.2-2010 (n=42 houses) influenced ventilation rates, moisture balance, indoor air

quality and self-reported physical and mental health outcomes. Average total air flow was nearly

twice as high for ASHRAE 62.2-2010 (79 vs. 39 cfm). Volatile organic compounds, and carbon

dioxide were all significantly reduced for the newer standard and first-floor radon was

marginally lower, but for the older standard, only formaldehyde significantly decreased.

Humidity in the ASHRAE 62.2-2010 group was only about half that of the ASHRAE 62-1989

group using the moisture balance metric. Radon was higher in the basement but lower on the first

floor for ASHRAE 62.2-2010. Children in each group had fewer headaches, eczema and skin

allergies after weatherization and adults had improvements in psychological distress. Indoor air

quality and health improve when weatherization is accompanied by an ASHRAE residential

ventilation standard and the 2010 ASHRAE standard has greater improvements in certain

outcomes compared to the 1989 standard. Weatherization, home repair and energy conservation

projects should use the newer ASHRAE standard to improve indoor air quality and health.

Key words: Ventilation, Indoor Air Quality, Healthy Housing, Weatherization, Housing,

ASHRAE (American Society of Heating Refrigeration and Air Conditioning Engineers), retrofit

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 Practical Implications
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Weatherization (sometimes known as home energy retrofits) can improve energy conservation,

but can also adversely affect health if ventilation is not adequate. This study shows that using

ASHRAE ventilation standards improves indoor air quality and self-reported health. It also

shows significantly better outcomes when the newer ASHRAE 2010 standard is used, compared

to the old ASHRAE 1989 standard still commonly used by many weatherization and other

housing programs. Such programs should comply with the newer ASHRAE standard to improve

health and indoor air quality.

INTRODUCTION

In 2005, the World Health Organization (WHO) showed that of 25 housing risk factors,

12 had “sufficient evidence” to estimate disease burden, and ventilation was one of 11 that had

only “some evidence” linked to “respiratory and allergic health effects” (WHO, 2006). The

factors related to energy conservation for which there was sufficient evidence of a health effect

included: 1) Heat and related temperatures and winter excess mortality; 2) Cold indoor

temperatures and winter excess mortality; 3) Radon exposure in dwellings and cancer; 4)

Neighborhood and building noise and related health effects; 5) Humidity and mold in dwellings

and related health effects; and 6) Hygrothermal conditions and house dust mite exposure. Some

of these, such as radon exposure and moisture, may be partially addressed by energy

conservation work such as sealing of basements and foundations. Additionally, many energy

conservation programs incorporate some health & safety measures such as installation of plastic

sheeting as a moisture barrier over bare earth in foundation areas.

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 The finding of only “some” evidence of ventilation effect on health was also upheld more
Accepted Article
recently (Jacobs et al., 2010) and a recent authoritative review of ventilation and health

concluded that, while there is some evidence of health improvements from better ventilation,

mainly in office buildings, “the need remains for more studies of the relationship between

ventilation and health, especially…in buildings other than offices” (emphasis added) (Sundell et

al., 2011). Some energy conservation practices reduce fresh air supply to the building,

underscoring the need for further investigation (Fisk et al., 2002).

The role of ventilation in diluting various airborne contaminants has been well

established for over 50, indeed thousands of years (Pliny the Younger, 2nd century AD)

(American Conference of Governmental Industrial Hygienists, 1951). For example, in the

healthcare community, early quantification of dilution was recognized in the form of the Wells-

Riley equation, which relates rate of infection from airborne pathogens to air changes per hour

with fresh air (Riley et al., 1978); increased ventilation rates are associated with reductions in

infections. Similar relationships between ventilation rates and health have been found in

barracks/dormitories (Brundage et al., 1988), offices (Mendell, 1983), and classrooms (Riley et

al., 1978). In fact, ASHRAE recommended ventilation rates for homes have varied considerably

over the last 75 years, from 30 cfm/person to as low as 5 cfm/person. Within the last quarter of a

century the target residential ventilation rates in ASHRAE standards have remained relatively

unchanged at about 15 cfm/person, although there have been significant differences in how the

ventilation rate has been calculated and obtained (Sherman, 2015). However, there is a paucity of

data on health effects associated with dilution through fresh air from uncontrolled infiltration vs.

ventilation driven by controlled mechanical systems, one of the key differences between the two

ASHRAE standards examined here.

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 Study of ASHRAE standards is particularly important now, because energy conservation
Accepted Article
in residential structures is increasing in extent, frequency and scope. About one-fourth of the

nation’s energy consumption is associated with residential building operation (U. S. Department

of Energy, 2010). Although many earlier studies have documented how energy conservation

practices in the 1970s and 1980s could contribute to mold and moisture and other problems

(Sundell et al., 2011), only a few studies have demonstrated how modern home energy

conservation can improve health. A recent study of multifamily residential buildings undergoing

weatherization (Wx) showed significant or marginally significant improvements in general

health, sinusitis, hypertension and the use of rescue asthma medication (Wilson et al., 2014).

However, asthma symptoms and problems sleeping due to asthma significantly worsened in that

study, possibly confounded by the reduced use of asthma medications. One Canadian study that

examined new homes built with energy efficient practices (Leech et al., 2004) demonstrated

significant improvements in throat irritation (p<0.004), cough (p<0.002), fatigue (p<0.009) and

irritability (p<0.002). Another study in New Zealand (Howden-Chapman et al., 2007) showed

that improved insulation was associated with a reduced odds ratio in the insulated homes of fair

or poor self-rated health (adjusted odds ratio [AOR] of 0.50), self-reports of wheezing in the past

three months (AOR of 0.57), self-reports of children taking a day off school (AOR of 0.49), and

self-reports of adults taking a day off work (AOR of 0.62). The study also showed that visits to

medical practitioners were less often reported by occupants of insulated homes (AOR of 0.73);

hospital admissions for respiratory conditions were also reduced (AOR of 0.53, but it was not

statistically significant (p=0.16). The study showed that insulating existing houses led to a

significantly warmer, drier indoor environment and resulted in improved self-rated health, self-

reported wheezing, days off school and work, and visits to general medical practitioners as well

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 as a trend for fewer hospital admissions for respiratory conditions. The “Heat or Eat” study
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found that families with reduced costs for energy as a result of receiving fuel assistance had a

reduced odds ratio of being at nutritional risk for growth problems and a lower odds ratio of

hospitalization (Frank and Neault, 2006).

In 2000, the National Academy of Sciences Institute of Medicine released a review of the

research on asthma and its relationship to indoor air quality (National Academy Press, 2000),

concluding that triggers, including certain pollutants such as nitrogen oxides (NO, NO2) are

involved in the worsening of existing asthma. These are products of combustion that can be

reduced by Wx and energy conservation retrofits, which improve combustion efficiencies of

appliances, reducing their entry into indoor air. This review also stated, “Measured data

quantifying the influence of ventilation rates on indoor concentrations of indoor-generated

pollutants are surprisingly limited, particularly for pollutants associated with asthma.”

This study was undertaken to help fill the knowledge gap on residential ventilation and

health outcomes in the context of Wx. It examines two different ASHRAE ventilation standards

that, in common practice, have different endpoints in terms of fresh air supplied to the home

(fresh air from infiltration only vs. providing additional fresh air from mechanical ventilation). It

also examines the impact of those endpoints on indoor air quality and the self-reported health of

the occupants. The differences between the two standards drive ventilation design of both new

and existing residential structures beyond the Wx context studied here.

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 METHODS
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Study Design & Hypotheses

We used a randomized study design in which all houses at baseline had no automated

mechanical ventilation and were randomly assigned into either the ASHRAE 62-1989 Wx group

(with infiltration as the main fresh air delivery method) or the ASHRAE 62.2-2010 Wx group

(with mechanically controlled ventilation). The first group served as the control group, while the

second served as the study group, because the older ASHRAE standard is still widely used

during Wx. There was no group that received no Wx, because the intent of this study was to

compare the effect of Wx using either of two ventilation standards, not if Wx itself improves

health. Both ASHRAE ventilation standards have airtightness triggers for requiring mechanical

ventilation, above which no additional mechanical ventilation is required. However, the level at

which ASHRAE 62-1989 requires mechanical ventilation is much tighter than it is for ASHRAE

62.2-2010 and so, in practice, homes complying with ASHRAE 62-1989 are typically tightened

only to the extent possible without adding mechanical ventilation. Homes weatherized with

ASHRAE 62.2-2010 usually require mechanical ventilation in order to obtain adequate fresh air.

This study has two hypotheses: 1) There is improved health and indoor air quality after

homes are weatherized with a ventilation standard; and 2) adopting ASHRAE 62.2-2010 results

in greater health and indoor air quality improvements compared with using ASHRAE 62-1989 in

the context of Wx.

Many indoor contaminants and health effects have seasonal variability. In this study,

homes were recruited and tested throughout the year during the normal work flow of the

participating Wx agencies. The process of randomly assigning homes to either the ASHRAE 62-

1989 group or the ASHRAE 62.2-2010 group resulted in similar numbers of homes in each

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 group being tested within a season. Therefore, although seasonal variability may impact
Accepted Article
individual homes, it is not a significant issue when comparing the two groups.

Ventilation & Weatherization

Wx work in approximately half of the homes complied with ASHRAE 62-1989 (which

Wx agencies doing work under the U.S. Department of Energy’s (DOE) Weatherization

Assistance Program (WAP) have traditionally used until recently, and which other programs

continue to use) and the other half complied with the more recent ASHRAE standard 62.2-2010.

The home ventilation modifications were done during Wx work performed in low-income

housing in Cook County, IL and various locations in Indiana.

The primary building tightening techniques used in Wx involve sealing large bypasses

between the indoor conditioned spaces and unconditioned spaces such as attics. Common

bypasses include, but are not limited to, plumbing and other utility cavities, open soffits, cavities

around chimneys, older can lights, missing top plates, and balloon framing. Air sealing typically

involves covering large openings with rigid materials such as wood or drywall, or using airtight

insulation such as rigid foam or expandable foam, dense-pack insulation in walls and

replacement of broken glass in windows if needed.

At baseline and immediately following the Wx work, building airflow performance and

ventilation were measured using blower door tests, zone pressure diagnostics, ventilation fan

flow rates and duct tightness measurements. The blower door test uses a calibrated fan to

depressurize a fully closed-up house by a specified amount, typically 50 pascals (Pa). The leakier

the house, the more airflow through the fan is required to generate this depressurization. The

airflow through the fan with the house depressurized by 50 Pa is commonly referred to as CFM50

[L/s @ 50 Pa] (cubic feet per minute at 50 Pa [liters per second at 50 Pa]). The resulting airflow,

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 in CFM50, was then used to estimate average natural air infiltration rates (i.e., rates at normal
Accepted Article
conditions without the blower door operating) (ASHRAE 2004, ASHRAE 2006).

The natural infiltration rates after Wx were compared with ASHRAE-required

ventilation rates to determine whether (and how much) mechanical ventilation was required.

Those determinations, in turn, depend on whether ASHRAE Standard 62-1989 or ASHRAE

Standard 62.2 is used (the latter was the current ASHRAE residential ventilation standard during

the field work). Both ASHRAE 62-1989 and 62.2-2010 account for natural infiltration based on

a blower door test, but ASHRAE 62-1989 requires less outdoor (fresh) air ventilation than

ASHRAE-62.2-2010. For this study, all the ASHRAE 62.2-2010 homes required mechanical

ventilation, but none of the ASHRAE 62-1989 homes did.

Ventilation was calculated using the AIM-2 model for stack-induced infiltration and

combined with automatic mechanical ventilation to get the overall mechanical ventilation rate

before and after Wx (Walker and Wilson, 1990) (ASHRAE, 2013). The AIM-2 model uses the

indoor-outdoor temperature difference, the height of the building, and the foundation type in

conjunction with the blower door result of house leakage to estimate natural infiltration. The

natural infiltration was combined with mechanical ventilation rates using the 0.5 rule (Palmiter

and Bond, 1991).

ASHRAE 62-1989 homes were tightened to no lower than a defined building tightness

limit (BTL), such that homes have no added mechanical ventilation, consistent with typical Wx

practice. ASHRAE 62.2-2010 homes were not sealed to a pre-determined limit. Instead,

ASHRAE 62.2-2010 homes all received mechanical ventilation, commonly using an exhaust fan,

usually in a bathroom but in some cases in a kitchen or common area. In short, ASHRAE 62-

1989 homes did not receive mechanical ventilation, but the ASHRAE 62.2-2010 homes did.

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Accepted Article
Indoor Air Quality Measurements

Long-term continuous measurement of temperature and relative humidity was

accomplished with data loggers (LASCAR-EL-USB-2), with measurements continuing

throughout each home’s study period, nominally 6 months. Over a nominal one-week period

before and immediately after Wx in both sets of homes, passive air sampling concentrations were

measured and logged for carbon dioxide (CO2) (Telaire 7001 + U12 dataloggers) and carbon

monoxide (CO) (LASCAR-EL-USB-CO datalogger). Radon samples were collected with

AccuStar diffusion barrier charcoal canisters, and analyzed using standard EPA method #402-R-

92-004 by AccuStar Labs in Medway, MA, accredited by National Environmental Health

Association and licensed by Illinois IEMA Division of Nuclear Safety and Indiana State

Department of Health. Passive sampling badges were used to collect total volatile organic

compounds (TVOCs) (3-M Organic Vapor Badge 3520), and formaldehyde (UMEX 100).

TVOCs were analyzed by gas chromatography (GC) with a flame ionization detector (FID), and

formaldehyde was analyzed by high performance liquid chromatography (HPLC) with UV

detection at Wisconsin Occupational Health Laboratories (WOHL), Madison, WI. WOHL is

accredited by AIHA LAP LLC for industrial hygiene methods with GC/FID and HPLC/UV.

Passive samples were collected at nominal breathing zone height in living areas (and basement

areas for radon). The CO and CO2 datalogger files were analyzed by the study team. When a

home had a basement radon sampler installed, temperature and relative humidity were measured

in both the basement and on the first floor of the home.

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 Self-Reported Health Interview
Accepted Article
A structured health interview drawn from the US Centers for Disease Control’s (CDC’s)

National Health Interview Survey, the Behavioral Risk Factor Surveillance System (BRFSS) and

the National Survey of Lead and Allergens in Housing (NSLAH) was utilized. This tool was

previously used in several other healthy housing studies. It includes physical and mental health

questions, as well as questions about housing condition. The interview was used to determine if

self-reported housing conditions and health changed between baseline and six months post-Wx

within each of the two groups and between the two groups. The adults answered questions about

their own health and the health of up to 4 children in the home.

To assess mental health, the NHIS portion of the health interview included two summary

tools, a measure of “serious psychological distress (SPD)” in adults and a “strengths and

difficulties” score for children. To ascertain the impact of Wx on adult psychological distress, six

questions (feeling sad, nervous, restless, hopeless, worthless, or that everything was an effort)

were used to measure the prevalence of SPD using the index developed by Kessler et al. (2002).

Each question asked how often the respondent experienced this symptom during the past 30

days, with responses ranging from 0 (none of the time) to 4 (‘‘all of the time’’) and were

summed across the six questions to yield a total score ranging from 0 to 24. An SPD score of 13

or more is used to distress (Dey and Lucas, 2006).

To assess child behavior and emotions, adult participants were asked four questions from

the “Strength and Difficulties Questionnaire” (SDQ) to determine if children were poorly

behaved, worried, unhappy, depressed or tearful; and had a poor attention span. Possible

responses were 0 (not true), 1 (sometimes true), and 2 (often true). The four responses were

summed to yield a total SDQ score ranging from zero to 8, with higher scores indicating more

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 difficulties (Pastor et al., 2012). Although we only asked 4 of the 5 questions included in the
Accepted Article
validated SDQ, we believe it is still a useful metric but results should be interpreted with caution.

To be included in the health interview analysis, both baseline and post-Wx interview data

had to be available for the dwelling. We required that the post-Wx interview be collected at least

4 months after the Wx completion. Data for specific questions that asked about events in 12-

months at baseline but “since Wx” at follow-up were excluded in 21 homes with < 6 months in

the home since Wx.

Statistical Methods

For nominal variables, we used Fisher’s exact test to determine if the percentages in the

ASHRAE 62-1989 group significantly differed from the percentages in the ASHRAE 62.2-2010

group at baseline. For continuous variables, we compared baseline group means using two-

sample t-tests. For ordinal variables, we compared the baseline group mean scores using

Cochran-Mantel-Haenszel (CMH) tests.

For dichotomous variables (e.g., yes/no), the CMH test was used to determine if the

percent “yes” was different at baseline vs post-Wx. Weighted least squares (WLS) were used to

determine if the change in percent “yes” from baseline to post-Wx for the ASHRAE 62-1989

group differed from the change for the ASHRAE 62.2-2010 group. For ordinal variables (e.g.,

frequency of exhaust fan use, frequency of asthma symptoms), the CMH mean score was used to

test if, within each group, mean baseline scores differed from mean post-Wx scores. The CMH

mean scores were used to determine if the changes in mean scores from baseline to post-Wx

differed in the two groups.

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 For continuous variables, paired t-tests on log-transformed variables were used to
Accepted Article
compare baseline and post-Wx geometric means (GM). Two-sample t-tests on log-transformed

variables were conducted to determine if the changes in GM concentrations from baseline to

post-Wx differed in the two ventilation groups. SAS version 9.4 (SAS Institute, Inc., 2002-2012)

was used for all health interview analyses and STATA 12 (StataCorp., 2011) was used for all

other analyses. For all statistical analyses, significance is defined as p<0.05 and marginal

significance is defined as 0.05≤p<0.1.

Data Exclusion

Indoor Air Quality Two homes were removed from all analyses because either their

baseline or post-Wx carbon dioxide measurements indicated that windows were open during all

or most of the sample period, which prevented an interpretation of the ventilation system

effectiveness (participants had been asked to keep windows closed during the sampling periods).

After these two homes were removed, data analysis of formaldehyde and TVOC

contaminant levels was done in two ways, one with all data included and one with extreme

values removed. The reason for excluding some extreme values was that these data from a small

number of homes may obscure results for the vast majority of homes. Data exclusion included

four homes that had pre-Wx formaldehyde levels below 7 ppb, which was chosen to be

consistent with the California EPA chronic reference exposure level (CREL) (California Office

of Environmental Hazard Assessment, 2014). The rationale was that if there was little of the

contaminant present in the first place, then it would be difficult to detect a further decrease due to

Wx and ventilation. For TVOCs, data exclusion included two homes with values that were 2-3

times greater than all other values measured across the cohort, suggesting unusual but unknown

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 TVOC sources were present. This included one home in the 62-1989 group with a high value at
Accepted Article
baseline and one home in the 62.2-2010 group with a high value following Wx. For radon,

homes that had baseline results below the laboratory detection limit of 0.4 pCi/l were excluded.

A discussion of the impacts of these exclusions is included in the “Results” section.

Health Interview Baseline interview data were collected in 79 dwellings between

February 2012 and March 2014. Post-Wx interview data were collected between November 2012

and November 2014 (1.6 to 15.3 months after Wx). Interview data for residents of 7 dwellings

were excluded from analysis because their post-Wx interview visits were too close to the

intervention to expect a noticeable health outcome (between 1.6 and 3.9 months). We did not

exclude other data for these units. The final interview dataset was comprised of 72 dwellings that

had post-Wx interviews conducted between 4 and 15.3 months post-Wx (mean ASHRAE 62-

1989: 7.7 months, ASHRAE 62.2-2010: 7.7 months). The mean number of months for the two

groups was not significantly different (p=0.973). Due to small sample sizes for each group, data

were not further stratified by state (Illinois and Indiana). For the ASHRAE 62-1989 group, health

interview data were available for 34 adults and 47 children living in 35 dwellings (23 in Illinois

and 12 in Indiana). In one ASHRAE 62-1989 dwelling in Illinois, a different adult was

interviewed at baseline and follow-up; therefore, their health data were excluded from the dataset

while housing condition data were included. For the ASHRAE 62.2-2010 group, interview data

were available for 37 adults and 60 children living in 37 dwellings (23 in Illinois and 14 in

Indiana).

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 RESULTS
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Ventilation

At baseline, none of the homes had existing whole-building automated ventilation. After

Wx, none of the ASHRAE 62-1989 homes had whole-building automated ventilation, but all

ASHRAE 62.2-2010 homes had such mechanical ventilation installed, typically via a single

exhaust fan in the bathroom. Automation was typically implemented by running this fan

continuously, but in some cases, when required flow rates were small, the fan was controlled to

operate intermittently, i.e. for a specified amount of time each hour without occupant

intervention. Table 1 shows the leakage rates (from blower door tests) and calculated ventilation

flow rates of the homes before and after Wx. Ventilation flow rates were based on normal

operating conditions, using blower door test results and environmental data collected during each

nominal one-week contaminant sampling period combined with the measured exhaust fan flow

rates. Exhaust fan flow rates were measured under normal operation. Exhaust fan flow sizing

was based on the ASHRAE 62.2-2010 calculation procedure, which uses occupancy and square

footage of the home, increases in ventilation rate due to insufficient local exhaust in kitchens and

bathrooms (as applicable), and credits for estimated infiltration from the blower door tests. This

calculation procedure results in a wide range of actual required installed flow rates (Table 1).

The mean baseline leakage rates were not statistically different between the two groups

(p=0.511). Both groups showed a statistically significant reduction in the mean leakage rate post-

Wx (both p<0.001). The mean leakage reductions were not statistically significant between the

two groups (p=0.596). Both sets of homes had an average 28% drop in leakage rates for the 62-

1989 homes and 26% for the 62.2-2010 homes, showing the reduction in unplanned air flows

and increased energy performance that are expected with Wx activities. None of the ASHRAE

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 62-1989 homes received automated mechanical ventilation, whereas the 62.2-2010 homes had an
Accepted Article
average of 60 cfm delivered by automated mechanical ventilation through exhaust fan

installation. At baseline, the two groups had similar overall mean ventilation rates; however,

after Wx, the 62.2-2010 group had about double the average ventilation rate of the 62-1989

homes (Table 1).

Moisture Balance
Moisture balance is the difference of vapor pressure between indoors and outdoors and

was used to characterize humidity in the homes. During heating season, houses typically have

higher vapor pressure indoors than outdoors. Because the difference is also dependent on outdoor

temperature, the analysis technique involves performing a linear regression to estimate the

moisture balance at 0 ºC and that value is used to characterize the home. This analysis technique

is derived from ISO Standard 13788 (ISO, 2012) and has been used previously (Francisco and

Rose, 2010). Prior to Wx the two groups of homes had no significant difference in moisture

balance (p=0.591) (Table 2). After Wx, both groups had lower moisture balance (i.e., were drier)

based on long-term data logger results; however, only the ASHRAE 62.2-2010 group’s reduction

was significant (p<0.001), and the ASHRAE 62.2-2010 group’s lower moisture balance was

significantly different from ASHRAE 62-1989’s (p=0.008).

Demographics

Adults in the two groups did not significantly differ from each other based on mean age,

level of education, race, income, and number of years lived in residence prior to baseline (Table

3). On average, adults in both groups had lived in their homes for 13.5 years prior to baseline

visits. The majority of adults were either non-Hispanic White (38%) or non-Hispanic Black

(38%) and female (83%), with a mean age of 48 years at the baseline visit. Annual household

income for 72% of dwellings was less than $30,000 at baseline. Two-thirds (67%) of adult

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 participants were either high school graduates, had their GED or some college. Children in both
Accepted Article
study groups were a mean age of 9.5 years, with a roughly equal gender distribution. Hispanic,

non-Hispanic Black, and non-Hispanic White were the primary races of study children with

proportions differing between the ASHRAE 62-1989 group (45%, 23%, and 28%, respectively)

and the ASHRAE 62.2-2010 group (23%, 42%, and 28%, respectively) (p=0.022).

Air Contaminants

Geometric mean (GM) concentrations for formaldehyde, TVOCs, basement radon, first

floor radon, and carbon dioxide are presented by pre-Wx, post-Wx, and the net change (minus

signs mean a reduction, plus sign means an increase) in Table 4 (extreme values excluded as

described in the methods section). In this table, p-values in the rows with full sample or

subsample results correspond to the changes from pre-Wx to post-Wx; the p-values in the rows

indicated by “p-value (between groups)” correspond to the differences in these changes between

the two groups. For the ASHRAE 62.2-2010 group, post-Wx GM concentrations of

formaldehyde, TVOCs, and CO2 were all significantly reduced (p<0.05) and first-floor radon

was marginally significantly lower than baseline concentrations (p=0.067). For the ASHRAE 62-

1989 group, the only significant reduction was for formaldehyde. The fact that both groups

showed similar reductions in formaldehyde suggests that ventilation is not the driver for

formaldehyde reductions.

First floor radon was reduced significantly in the 62.2-2010 group. Basement-level radon

marginally increased in the 62.2-2010 group (p = 0.073). This could be a concern when homes

are designed for basement occupancy. Such homes constituted 68% of the study sample.

However, of the 51 homes for which valid pre- and post-Wx basement radon measurements were

obtained, only 29 homes had basements designed for possible occupancy and of these, 26 were

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 in Illinois where radon levels were generally lower. Only 16% (3 of 18) Indiana homes with
Accepted Article
valid measurements had basements designed for occupancy, and in 2 of these 3 homes the post-

Wx basement radon level was 1 pCi/l or less. For the 26 applicable Illinois homes the pre- and

post-Wx geometric means were 1.3 pCi/l and 1.6 pCi/l, respectively; the maximum was 4.4

pCi/l. Therefore, though there was a marginally statistically-significant increase in basement

radon in the 62.2-2010 group, most homes with basements designed for occupancy had levels

below the EPA action level.

When the two groups are combined, all GM contaminant levels except basement radon

declined between baseline and post-Wx; however, only the decrease in formaldehyde and CO2

concentrations were statistically significant. This is due to the lack of statistical significance for

the 62-1989 group for all other contaminants and perhaps small overall sample size. The

combined group GM basement-level radon level increased slightly although not significantly

(p=0.330).

There were no significant differences in the pre- to post-concentration between the two

groups for any of these contaminants, even though both groups had improved indoor air quality

and in general the ASHRAE 62.2-2010 homes showed greater improvements than the 62-1989

homes for carbon dioxide, formaldehyde, first-floor radon, and moisture. Although basement-

level radon increased in 62.2-2010 homes, living area radon decreased.

For formaldehyde, the inclusion of the four homes with less than 7 ppb at baseline

resulted in the changes from pre- to post-weatherization being not statistically significant,

obscuring the trend seen for the 75 homes with substantial formaldehyde levels. For the four

homes that started with 7 ppb or lower, two had post-weatherization levels of 13 ppb, one was 27

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 ppb, and one was 30 ppb. About one-third of the homes had increases in formaldehyde, and the
Accepted Article
increases in these four homes within the typical range as for other homes that had increases.

For radon, there were five homes with levels below the detection limit of 0.4 pCi/l in the

basement pre-weatherization and seventeen homes with levels below the detection limit on the

first floor pre-weatherization. Of the 5 homes with low levels in the basement, two had levels

below the detection limit post-weatherization, one had a level of 0.7 pCi/l, and two had levels of

about 1.5 pCi/l. None of these levels is near the U.S. Environmental Protection Agency’s action

level of 4 pCi/l, and the uncertainty of the actual level that was below the detection limit was a

significant fraction of the signal of apparent change from pre- to post-weatherization. For the 17

homes with first floor radon levels below the detection limit, nine had post-weatherization levels

below the detection limit, four had levels of 0.6 pCi/l, one had a level of 0.8 pCi/l, and the

remaining three had levels ranging from 1.4 to 3.2 pCi/l. As for the basements, all of these levels

are below the EPA action level and the uncertainty of the actual level that was below the

detection limit was a significant fraction of the signal of apparent change from pre- to post-

weatherization in virtually all pertinent homes.

Carbon Monoxide

Unlike the other contaminants, which typically have continuous sources (e.g., furnishings

and carpets for formaldehyde, cleaning and personal care products for TVOCs, soil gas for

radon), CO concentrations are highly event-driven. In general, conditions related to combustion

appliances and usage drives CO results. This means that general whole-building ventilation is

usually irrelevant for CO, and therefore comparisons between 62-1989 and 62.2-2010 are not

pertinent. The most common cause of elevated CO in these homes was the use of cooking

appliances, as evidenced by the fact that elevated CO levels often appeared at about meal times

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 and at about the same time each day. Most instances of higher CO levels were of relatively short
Accepted Article
duration (e.g. typically less than 2 hours, much less than the EPA time-averaging period of 8

hours), and levels usually decayed to zero over the next several hours. Given the number of

event-driven signals, evaluation of CO centered on the frequency with which CO levels were

elevated before and after Wx. Average CO was considered elevated if the average concentration

over each nominally one-week sampling period exceeded 4.5 ppm, which is half of the EPA 8-

hour allowable level for outdoor air (9 ppm) (US EPA, 2011), and maximum CO was considered

elevated if the maximum concentration was at least 9 ppm. The Cochran-Mantel-Haenszel

(CMH) test was used to compare whether the frequency of elevated readings at baseline differed

from the post-Wx frequency (Table 5). In this table, results are presented by state because

Indiana had a policy that allows for non-federal money to be used to address high-CO stoves and

so these high-emitting appliances were typically replaced in Indiana, whereas Illinois did not

have such an option.

Table 5 shows that there were very few homes that had elevated average CO levels, and

that about a third of homes had elevated maximum readings (which typically lasted only a short

time, much less than the referenced EPA 8-hour period). There were fewer homes that exceeded

the average of 4.5 ppm following Wx in all groups, but these changes were not statistically

significant (p>0.05). The same number of homes had maximum values of 9 ppm or above post-

Wx, with two more exceeding 9 ppm post-Wx in Illinois and two less in Indiana. In Indiana there

were no homes that exceeded an average of 4.5 ppm post-Wx, but this was not a statistically

significant change from pre-Wx (p=0.727).

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 Health Interview Results
Accepted Article
Children in both groups had significant improvements in reports of frequent or severe

headaches between baseline and post-Wx (ASHRAE 62-1989 p=0.083; ASHRAE 62.2-2010

p=0.001), with the ASHRAE 62.2-2010’s reduction being significantly better than that of

ASHRAE 62-1989 (p=0.041) (Table 6). Respiratory allergies appeared to affect fewer children

in both groups after Wx but did not reach statistical significance. There were reductions in

eczema and skin allergies in each group (ASHRAE 62-1989 p=0.083 and ASHRAE 62.2-2010

p=0.059) but there was not a significant difference between groups (p=0.773). The general health

of children in the ASHRAE 62-1989 group significantly improved between baseline and post-

Wx (p=0.004), while that of the ASHRAE 62.2-2010 children remained the same (p=0.431)

(Table 6). Most adult respondents reported that children’s general health was very good over the

course of the study. Neither group had a significant change in their mental and emotional

strengths and difficulties (p=0.530 and 0.921, respectively) (Table 7). Study children in both

groups appeared to be well-behaved.

However, adults in each group had significant reductions in psychological distress

between baseline and post-Wx. The mean change for the ASHRAE 62.2-2010 group, however,

was not significantly different from the change for the ASHRAE 62-1989 group’s mean change

(p=0.361). At both baseline and post-Wx, the adult psychological distress scores in both groups

were well below the SPD level of 13 (mean=5.0 at baseline and 3.7 at post-Wx) (Table 7). At

both baseline and post-Wx, adults in both groups reported generally good to very good general

health.

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 Housing Characteristics and Condition
Accepted Article
Table 8 shows the housing characteristics for the sample. Percentages shown in the table

correspond to the subsample to which each ventilation standard was applied. As shown by the p-

values, dwellings in the two groups did not significantly differ for any baseline housing

characteristics. On average, dwellings in both groups were 50 to 60 years old, 1,300-ft2, single-

family detached homes, with 1- to 1.5 stories and either no or detached garages. Central air

conditioning was present in over three-quarters of study dwellings, and almost all had forced air

heat fueled by natural gas.

Fewer ASHRAE 62.2-2010 residents (8% reduction, p=0.414, n=26) and more ASHRAE

62-1989 residents (16% increase, p=0.157, n=25) reported smoke inside their homes at post-Wx

compared with baseline, with the former’s reduction being marginally-significantly different

from ASHRAE 62-1989’s increase (p=0.097) (Figure 1). While smoke from cigarettes, cigars,

and pipes slightly decreased for both groups, the change in reported candle and incense smoke

decreased for ASHRAE 62.2-2010 (n=15) but increased for ASHRAE 62-1989 (n=13)

(p=0.064). Data on smoke inside homes were reported because it could have an impact on air

quality, not because we expected that smoke inside homes would be affected by ventilation.

Between baseline and post-Wx, the percentage of ASHRAE 62-1989 participants (n=35)

reporting cockroaches slightly increased, while the other group (n=37) showed a slight decrease,

but neither reached statistical significance (Figure 1). ASHRAE 62-1989 (n=35) differed from

ASHRAE 62.2-2010 (n=37) in the percentage of residents using traps, bait stations or poisons to

control mice or rats, but the former’s reduction (20%) was 15% better than ASHRAE 62.2-

2010’s reduction (5%) (p=0.090).

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 Between baseline and post-Wx, significantly fewer people in each group reported water
Accepted Article
or dampness issues in their home due to broken pipes, leaks, heavy rain, floods, or other reasons,

with similar reductions observed for both groups (ASHRAE 62-1989 n=35; ASHRAE 62.2-2010

n=37) (Figure 2). This is consistent with the moisture balance findings presented above. Over the

same time period, both groups experienced non-significant reductions in most other housing

deficiencies, including mildew odors or musty smells, use of a dehumidifier or humidifier,

presence of mice or rats, and indoor temperatures too hot or too cold in summer or winter. There

were no differences in size of reductions between the two study groups.

Discussion

In the ASHRAE 62-1989 homes no mechanical ventilation was added, and the air sealing

that reduced uncontrolled ventilation caused overall air exchange rates to go down. Even with

lower rates, improvements in IAQ could still occur due to such things as removal of problematic

materials, improved separation of living space from garages and crawl spaces, addressing

moisture problems, addressing combustion safety problems, etc.

The chief limitation of this study design is that it was not possible to measure sources of

air contaminants, such as new particle board for formaldehyde. Ventilation alone cannot be

expected to keep air contaminants below certain levels without addressing sources. Another

limitation was the 6-month followup period necessitated by the duration of the grant agreement.

Ideally, a longer followup period is needed, because health would not necessarily be expected to

improve over a shorter time period. A strength of the study was its ability to randomize housing

units into the two study groups, reducing selection bias.

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 This study shows that both indoor air quality and self-reported health improved during
Accepted Article
Wx and that for most contaminants the more recent ASHRAE 62.2-2010 standard appeared to be

superior. Formaldehyde and TVOC analyses were conducted with some results excluded due to

low (in the case of formaldehyde) or extremely high (in the case of VOCs) results. For

formaldehyde, if the four homes with baseline levels of 7 ppb or less were included, the changes

were not significant for all homes, ASHRAE 62-1989 homes, and ASHRAE 62.2-2010 homes

(p=0.169, 0.597, and 0.162, respectively). All these changes were significant with the low

baseline results excluded. For TVOCs, if the two homes with readings 2-3 times the next highest

reading were included, the changes were not significant for all homes, ASHRAE 62-1989 homes,

and ASHRAE 62.2-2010 homes (p=0.244, 0.753, and 0.177, respectively). When the outliers

were excluded, the change was only significant for ASHRAE 62.2-2010 (p=0.041). The outliers

thus appeared to have a significant influence, likely due in part to the relatively small sample size

in this study. Larger studies should be done to confirm the findings from this small study.

It is unknown why there were significant reductions in formaldehyde in both groups of

homes, especially given that the 62-1989 homes were tightened but received no ventilation. The

results suggest that ventilation is not the primary driver of formaldehyde levels in these homes.

One possibility is that Wx activities in these homes beneficially impacted the source term,

perhaps by removing formaldehyde-producing sources. However, this is speculation.

Two homes in the radon dataset showed living level radon increases from below 4 pCi/l

(the level at which EPA recommends remediation) at baseline to above 4 pCi/l at post-Wx. One

of these two homes apparently had windows open at baseline, yielding an invalid radon test. The

other home increased from 3.8 pCi/l baseline to 4.8 pCi/l post-Wx. The pre-Wx value was nearly

4 pCi/l, and the difference between the two is well within the normal variation of radon expected

This article is protected by copyright. All rights reserved.

 in a one-week sampling period (Steck, 2005). As a result, it is not possible to conclude that any
Accepted Article
homes rose from below 4 pCi/l to above 4 pCi/l as a result of Wx activities.

The fact that the 62.2-2010 homes showed a negative impact on radon on basements but a

positive impact on radon on first floors has potentially major implications on radon policy if

these results are borne out in further studies. This phenomenon is qualitatively plausible; exhaust

ventilation depressurizes the house, potentially pulling in more soil gas AND more outdoor air.

However, the soil gas will enter basements whereas outdoor air will be primarily above-grade.

Therefore, basement concentrations may go up since there is little additional dilution in those

spaces, but first floor concentrations can go down because of the additional outdoor air dilution.

The net impact to residents would then depend on the balance of their time in the basement vs.

the first floor. If residents spend most of their time on the first floor, then these results would

suggest a benefit to residents. If some residents spend most of their time in the basement, such as

in homes with bedrooms in finished basements, then the results would suggest a detriment

resulting from exhaust-only ventilation installed on the first or second floor.

The time frame in some of the interview questions fluctuated. For example, baseline

questions about certain health conditions (e.g., headaches in children and sinusitis in adults)

asked if the person had experienced the condition in the “last 12 months.” In the post-Wx

interview, this phrase was changed to “since Wx.” In some of the housing condition questions

(e.g., resident used traps, bait stations or poisons to control mice/rats), no timeframe was

specified in the baseline question but the phrase “since Wx” was added to the post-Wx question.

Because the post-Wx visits were conducted between 4 and 15.3 months after Wx work was

completed (mean for each group was 7.7 months), the baseline and post-Wx timeframes for such

questions were not equal. Other questions did have an equal timeframe, asking either about

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 conditions “now” (e.g., frequency of exhaust fan use) or “in the past 3 months” (e.g., “need help
Accepted Article
handling routine needs”) at both baseline and post-Wx. The impact of unequal time periods on

participants’ answers is unknown but likely had some minor effect especially when the post-Wx

timeframe did not span all four seasons.

Adults in each group had significant improvements in psychological distress between

baseline and post-Wx. This finding could be due to the satisfaction with the Wx work, or it could

be due in part to the improvement in moisture or perhaps some other reason. One study found

that dampness or mold in the home was associated with depression (odds ratio=1.39, 1.44, and

1.34, for minimal, moderate, and extensive exposure, respectively), compared with no exposure

(Shenassa et al., 2007). Our moisture balance findings are also consistent with trends in musty

odors reported by the occupants. Further research is needed to understand the relationship

between mental health and housing condition, particularly moisture and related mold exposures.

This research has broad implications in the era of climate disruption and the need for

more resilient housing. Further studies are needed to better define the amount and method of

fresh outdoor air supply that is optimal for health and the energy savings achieved through

weatherization and reduction of unplanned air infiltration into homes.

Conclusion

Following Wx, ventilation air flows in the ASHRAE 62.2-2010 group were twice as great

compared to those in the ASHRAE 1989 group. The ASHRAE 62.2-2010 group also had

significantly lower indoor moisture balance, which is likely to reduce the potential for mold

contamination. The study shows that air quality and self-reported health outcomes improve when

Wx is accompanied by an ASHRAE residential ventilation standard and that the ASHRAE 62.2-

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 2010 standard enhances such improvements for certain outcomes. Larger studies over a longer
Accepted Article
follow-up period should be done to better understand variability and durability. This study

demonstrates that residential Wx can be done in a way that need not compromise health, but can

actually improve it and associated indoor air quality.

Acknowledgments: The authors would like to thank the residents who welcomed us into their

homes and took the time to participate in the study. We also want to thank the local Department

of Energy Wx programs in Indiana and Chicago, Harold Dawson of CEDA, Steve Nall and Dan

Phillips of INCAA, Burke Greenwood, formerly with CEDA, and Eugene Pinzer at the Office of

Lead Hazard Control and Healthy Homes at the US Department of Housing and Urban

Development. This project was funded by U.S. Department of Housing & Urban Development

(HUD Grant Number: ILLHH0230-10). The contents of this manuscript are solely the

responsibility of the authors & do not necessarily represent the official views of HUD.

REFERENCES

American Conference of Industrial Hygienists. (1951) Industrial Ventilation: A Manual of

Recommended Practice.

ANSI/ASHRAE (RA 2004) Air Leakage Performance for Detached Single-Family Residential
Buildings, Atlanta, GA, American Society of Heating, Refrigerating and Air-Conditioning
Engineers, Inc. (ASHRAE Standard 119-1988)

ANSI/ASHRAE (RA 2006) A Method of Determining Air Change Rates in Detached Dwellings,
Atlanta, GA, American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc.
(ASHRAE Standard 136-1993)

ASHRAE (2013) 2013 ASHRAE Handbook--Fundamentals. Atlanta, GA, American Society of

Heating, Refrigerating, and Air-Conditioning Engineers, Inc.

This article is protected by copyright. All rights reserved.

 Brundage, Scott R.M., Lednar, W.M., Smith, D.W., Miller, R.N. (1988) Energy efficient
buildings pose higher risk of respiratory infections JAMA Apr 8;259(14):2108-12l.
Accepted Article
California Office of Environmental Hazard Assessment (2014) Reference Exposure Levels,
http://www.oehha.ca.gov/air/Allrels.html

Dey, A.N. and Lucas, J.W. (2006) Physical and mental health characteristics of U. S. - and
foreign-born adults: United States, 1998-2003. Advance Data from Vital and Health Statistics,
369. U. S. Centers for Disease Control Division of Health Interview Statistics.
http://www.cdc.gov/nchs/data/ad/ad369.pdf.

Fisk, W. J., Brager, G., Burge, H., Cummings, J., Levin, H., Loftness, V., Mendell, M.J., Persily,
A., Taylor, S., and Zhang, J.S. (2002) Energy-Related Indoor Environmental Quality Research:
A Priority Agenda, Lawrence Berkeley National Laboratory report 51328.

Francisco, P. and Rose, W. (2010) Temperature and humidity measurements in 71 homes

participating in an IAQ improvement program. Proceedings of Thermal Performance of Exterior
Envelopes of Whole Buildings, XI, Florida, USA.

Frank, D. and Neault, N. (2006) Heat or eat: the low income home energy assistance program
and nutritional and health risks among children less than 3 year of age, Pediatrics, 118:5, e1293-
e1302.

Howden-Chapman, P. et al. (2007) Effect of insulating existing houses on health inequality, Brit
Med J, 334:7591.

Institute of Medicine (2000) Clearing the Air: Asthma and Indoor Air Exposures. Washington,
DC. National Academy Press.

ISO (2012) Hygrothermal Performance of Building Components and Building Elements --

Internal Surface Temperature to Avoid Critical Surface Humidity and Interstitial Condensation -
- Calculation Methods.

Jacobs, D.E., Brown, M.J., Baeder, A., Scalia, Sucosky, M., Margolis, S., Hershovitz, J., Kolb,
L., and Morley, R.L. (2010) A systematic review of housing interventions and health:
introduction, methods, and summary findings. JPHMP, S3–S8.

Joint Center for Housing Studies of Harvard University (2006). The State of the Nation’s
Housing, available at http://www.jchs.harvard.edu/sites/jchs.harvard.edu/files/son2006.pdf.

Kessler, R.C., Andrews, G., Colpe, L.J., Hiripi, E., Mroczek, D.K., Normand, S.L., Walters,
E.E., and Zaslavsky, A.M. (2002) Short screening scales to monitor population prevalences and
trends in non-specific psychological distress. Psychol Med, 32(6), 959–976.

Leech, J.A., Raizenne, M., and Gusdorf, J. (2004) Health in occupants of energy efficient new
homes. Indoor Air, 14(3), 169-173.

This article is protected by copyright. All rights reserved.

 Mendell, M. J. (1993) Non-specific symptoms in office workers: a review and summary of the
Accepted Article
epidemiologic literature. Indoor Air, 3, 227-236.

National Institute of Environmental Health Sciences. National Survey of Lead and Allergens in
Housing. Available at http://www.niehs.nih.gov/research/atniehs/labs/iidl/pi/enviro-
cardio/studies/nslah/index.cfm

Palmiter, L., and Bond, T. (1991) Interaction of mechanical systems and natural infiltration. In:
Proceedings of the AIVC 1991 Conference on Air Movement and Ventilation Control Within
Buildings, Vol 1, pp. 285-295. Coventry, Great Britain: The Air Infiltration and Ventilation
Centre.

Pastor, P.N., Reuben, C,A,, and Duran, C.R. (2012) Identifying emotional and behavioral
problems in children aged 4-17 years: United States, 2001-2007. U. S. Centers for Disease
Control and Prevention Office of Analysis and Epidemiology, National Health Statistics Report,
48, available at http://www. cdc. gov/nchs/data/nhsr/nhsr048.pdf

Pliny the Younger, (2nd Century AD). Epistles Book II.

Riley, R. C., Murphy, G., and Riley, R. L. (1978) Airborne spread of measles in a suburban
elementary school, Am J Epidemiol, 107, 421-32.

SAS Institute, Inc. (2002-2012) SAS: Version 9. 4. Cary, NC, USA.

Shenassa, E.D., Daskalakis, C., Liebhaber, A., Braubach, M., and Brown, M.J. (2007) Dampness
and mold in the home and depression: an examination of mold-related illness and perceived
control of one’s home as possible depression pathways. Am J Public Health, 97, 1893–1899.

Sherman, M. (2015) How ASHRAE set the rates for residential ventilation. ASHRAE J, 57(7),
20-23.

StataCorp LP. (2011) Stata Statistical Software: Release 12. College Station, TX.

Sundell J., Levin, H., Nazaroff, W.W., Cain, W.S., Fisk, W.J., Grimsrud, D.T., Gyntelberg, F.,
Li, Y., Persily, A.K., Pickering, A.C., Samet, J.M., Spengler, J.D., Taylor, S.T., and Weschler,
C.J. (2011) Ventilation rates and health: multidisciplinary review of the scientific literature.
Indoor Air, 21, 191-204.

U. S. Department of Energy (2010). Building Energy Data Book, D&R International, Ltd.
http://buildingsdatabook.eren.doe.gov/ChapterIntro1.aspx.

U.S. Centers for Disease Control and Prevention (Undated) Behavioral Risk Factor Surveillance
System, available at http://www.cdc.gov/BRFSS

U.S. Centers for Disease Control: National Center for Health Statistics (2009), National Health

This article is protected by copyright. All rights reserved.

 Interview Survey questionnaire, available at:
ftp://ftp.cdc.gov/pub/Health_Statistics/NCHS/Survey_Questionnaires/NHIS/2009/English
Accepted Article
U.S. EPA (2011) National primary ambient air quality standards for carbon monoxide,
Washington, D.C.

Walker, I. S., and Wilson, D. J. (1990) The Alberta Air Infiltration Model. Technical Report 71.
Edmonton, Alberta: University of Alberta, Department of Mechanical Engineering.

WHO European Centre for Environment and Health (2006) Report on the WHO Technical
Meeting On Quantifying Disease From Inadequate Housing, Bonn, Germany.

Wilson, J., Dixon, S.L., Jacobs, D.E., Breysse, J., Akoto, J., Tohn, E., Isaacson, M., Evens, A.,
and Hernandez, Y. (2014) Watts-to-Wellbeing: Does residential energy conservation improve
health? J Energy Efficiency, 7, 151-160.

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 Table 1. Baseline and Post-Wx Infiltration and Ventilation Rates
Pre-Wx Post-Wx
Accepted Article
Exhaust
Leakage Calculated Leakage Calculated
n fan flow
Group/Statistic rate Ventilation rate Ventilation
rate
(CFM50) Rate (cfm) (CFM50) Rate (cfm)
(cfm)
ASHRAE 62-
1989
Mean 34 3009 37.9 2153 0 39.2
Std. Dev. 764 25.1 702 0 31.4
Min 1420 11.3 950 0 7.7
Q1 2581 21.5 1743 0 17.4
Q3 3505 43.2 2442 0 46.7
Max 4927 116.2 4350 0 120.3
ASHRAE 62.2-
2010
Mean 41 2891 40.6 2102 60.2 79.2
Std. Dev. 1143 34.8 908 20.4 33.1
Min 550 3.5 626 12 23.0
Q1 2030 24.1 1642 45 56.3
Q3 3614 45.6 2410 73 94.1
Max 6012 202.4 5210 90 172.8

Table 2. Long-term Moisture Balance (Pa)

Group n Mean Pre- Wx Mean Post- P (within

Wx group) a

ASHRAE 62-1989 22 1,368 1,046 0.116

ASHRAE 62.2-2010 29 1,153 586 <0.001

P (between groups) b --- 0.591 0.008 ----

a
Paired t-test that there was a change in the mean from Pre- to Post-Wx
b
Two sample t-test that the change in the mean from Pre- to Post-Wx was different between the two groups

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 Table 3.Demographics
Adults Children
Accepted Article
Characteristic ASHRAE ASHRAE ASHRAE- ASHRAE
62-1989 62.2-2010 P 62-1989 62.2-2010 P
N=34 N=37 N=47 N=60
Age (years)
Minimum 19 26 1 1
0.386a 0.326a
Mean 47 50 10 9
Maximum 84 91 17 17
Highest Level of School
Completed (#/%)
Less than high school 1 (3%) 1 (3%)
Some high school 2 (6%) 3 (8%)
0.167b
High school graduate/GED 9 (26%) 17 (46%)
Some college 13 (38%) 9 (24%)
Associate degree 3 (9%) 5 (14%)
College graduate 6 (18%) 2 (5%)
Race (#/%)
Non-Hispanic Black 12 (35%) 15 11 (23%) 25 (42%)
(40.5%)
Non-Hispanic White 12 (35%) 15 13 (28%) 13 (28%)
0.730c 0.022c
(40.5%)
Hispanic 6 (18%) 6 (16%) 21 (45%) 14 (23%)
Asian 3 (9%) 1 (3%) 2 (4%) 0 (0%)
Other 1 (3%) 0 (0%) 0 (0%) 0 (0%)
Female Gender (#/%) 29 (85%) 30 (81%) 0.756c 22 (47%) 27 (45%) 1.00c
Annual Household Income (#/%)
<$10,000 6 (17%) 4 (11%)
$10,000-$19,999 12 (35%) 11 (30%)
$20,000-$29,999 8 (24%) 10 (27%) 0.108d
$30,000-$39,999 8 (24%) 7 (19%)
$40,000-$49,000 0 (0%) 4 (11%)
>$75,000 0 (0%) 1 (2%)
Years Lived in Home
Minimum 0.6 0.9
0.773
Mean 13 14
Maximum 45.4 47.9
a
Two-sample t-tests that mean age and mean years in home are different for the two groups
b
CMH test that the mean education scores are different for the two groups
c
Fisher exact tests that race and gender are different for the two groups
d
CMH test that mean income scores are different for the two groups

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 Table 4. Indoor air quality measurements.
Contaminant/group Pre-Wx Post-Wx Pre- to Post-Wx Change
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Percent Change in P (within
N GM GSD GM GSD
GM group)a
Formaldehyde (ppb)
All homes 71 28 1.7 23 1.6 -18% 0.002
62-1989 30 31 1.6 25 1.6 -19% 0.019
62.2-2010 41 26 1.7 21 1.6 -19% 0.041
p (between groups) b 0.723
TVOCs (ppb)
All homes 68 163 3.0 134 2.5 -18% 0.180
62-1989 31 124 3.0 124 2.7 0% 0.989
62.2-2010 37 204 2.9 142 2.5 -30% 0.041
p (between groups) b 0.209
Basement radon
(pCi/l)
All homes 51 2.6 3.0 3.0 3.0 15% 0.330
62-1989 23 3.0 3.2 2.9 3.4 -3% 0.888
62.2-2010 28 2.4 2.8 3.1 2.8 29% 0.073
p (between groups) b 0.266
1st floor radon (pCi/l)
All homes 46 1.8 2.4 1.4 2.5 -22% 0.143
62-1989 21 1.7 2.4 1.6 2.6 -6% 0.824
62.2-2010 25 1.9 2.5 1.3 2.4 -32% 0.067
p (between groups) b 0.304
Carbon Dioxide (ppm)
All homes 66 914 1.5 797 1.4 -13% 0.005
62-1989 29 888 1.5 810 1.4 -9% 0.266
62.2-2010 37 936 1.4 787 1.4 -16% 0.004
p (between groups) b 0.399
a
Paired t-test that there was a change in the GM from Pre- to Post-Wx
b
Two sample t-test that the relative change in the GM from Pre- to Post-Wx was different between the two groups
GM=Geometric Mean, GSD=Geometric Standard Deviation

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 Table 5. Carbon monoxide results.
# (%) of Homes Average>4.5 ppm # (%) of Homes Max ≥9 ppm
Accepted Article
State Pre-
N Post-Wx P N Pre-Wx Post-Wx pa
Wx
Illinois 1.000 16
47 3 (6%) 2 (4%) 47 18 (38%) 0.774
(34%)
Indiana 3 0.250
27 0 (0%) 27 6 (22%) 4 (15%) 0.727
(11%)
Combined 0.219 22
74 6 (8%) 2 (3%) 74 22 (30%) 1.000
(30%)
a
CMH test that there was a change in the percentage of home exceeding the threshold (4.5 ppm or 9 ppm) from
Pre- to Post-Wx

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Table 6. Changes in adult physical and mental health
ASHRAE 62-1989 Group ASHRAE 62.2-2010 Group ASHRAE
d d
N Pre- Post- Change P N Pre- Post- Change P 1989 vs
Outcome Wx % Wx, % Wx, % Wx, % ASHRAE
or or or or 2010
e
Mean Mean Mean Mean P
PHYSICAL HEALTH AND SAFETY:
 Mean general health scorea 34 2.8 2.5 -0.3 0.068 37 2.9 2.7 -0.2 0.237 0.636
 Mean score, health now 34 NA 1.8 NA NA 37 NA 1.6 NA NA 0.205
compared with before Wxb
 % sinusitis 24c 38% 21% -17% 0.157 26c 27% 15% -12% 0.083 0.691
 % hay fever 24c 4% 0% -4% 0.317 26 12% 4% -8% 0.317 0.681
 % chronic bronchitis
c
24 21% 17% -4% 0.317 26 15% 8% -8% 0.157 0.595
 % hypertension 34 35% 38% 3% 0.317 36 36% 39% 3% 0.317 0.967
 % injury while in or around home 34 6% 3% -3% 0.564 37 3% 5% 3% 0.564 0.412
 % need help handling routine 34 26% 24% -3% 0.317 37 22% 11% -11% 0.102 0.261
needs
MENTAL HEALTH:
 Psychological distress score 34 5.0 4.1 -0.9 *0.082 37 5.0 3.4 -1.6 0.008 0.361
 % physical, mental, or emotional 34 21% 24% 3% 0.564 36 19% 19% 0% 1.00 0.655
problem prevent working
a
Possible responses were scored as follows: Excellent=1, Very Good=2, Good=3, Fair=4, and Poor=5. Lower score indicates better health status.
b
Question asked if general health was better (score=1), the same (score=2), or worse (score=3) since Wx.
c
Question asked if person had the specified health problem in the 12 months before baseline but asked if they had the problem “since Wx” at
the Post-Wx visit. We excluded data for 21 adults (10 ASHRAE 62-1989 and 11 ASHRAE 62.2-2010) who had post-Wx visit <6 months after Wx to
the time period mismatch.
d
CMH test that there was a change in the percentage or mean score from Pre- to Post-Wx
e
CMH test that the change in the percentage or mean score from Pre- to Post-Wx was different between the two groups

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Table 7. Changes in children physical and mental health
ASHRAE 62-1989 Group
e
ASHRAE 62.2-2010 Group
e
N Pre- Post- Change P N Pre- Post- Change P 1989 vs
Outcome Wx, % Wx, % Wx, % Wx, % 2010
f
or or or or P
Mean Mean Mean Mean
PHYSICAL HEALTH AND SAFETY:
 Mean general health scorea 47 2.5 2.0 -0.5 0.004 60 2.0 1.9 -0.1 0.431 0.062
 Mean score, health now 47 NA 1.9 NA NA 60 NA 1.8 NA NA 0.676
compared with before Wxb
 % headaches 29c 17% 7% -10% 0.083 39c 44% 13% -31% 0.001 0.041
 % three or more ear infections
c
29 3% 3% 0% NA 39c 0% 3% 3% 0.317 0.311
 % hay fever
c
29 10% 3% -7% 0.157 39c 10% 5% -5% 0.414 0.821
 % respiratory allergy
c
28 14% 0% -14% 0.046 39c 26% 18% -8% 0.180 0.447
 % eczema or skin allergy 29c 21% 10% -10% 0.083 39c 28% 15% -13% 0.059 0.773
 % ADHD or ADD 47 2% 2% 0% NA 59 5% 7% 2% 0.317 0.314
 % learning disability 47 13% 11% -2% 0.317 59 3% 5% 2% 0.317 0.156
 % asthma 46 4% 4% 0% NA 59 17% 15% -2% 0.317 0.314
 % injury while in or around home 47 0% 4% 4% 0.157 60 2% 5% 3% 0.317 0.835
MENTAL HEALTH:
 Mean strengths and difficultiesd 47 1.6 1.5 -0.1 0.561 58 1.7 1.0 -0.7 0.001 0.101
NA=not applicable; p-value cannot be calculated because the responses at baseline and post-Wx were the same for each person.
a
Possible responses were scored as follows: Excellent=1, Very Good=2, Good=3, Fair=4, and Poor=5. Lower score indicates better health status.
b
Question asked if general health was better (score=1), the same (score=2), or worse (score=3) since Wx.
c
Question asked if person had the specified health problem in the 12 months before baseline but asked if they had the problem “since Wx” at the Post-Wx visit.
We excluded data for 39 children (18 ASHRAE 62-1989 and 21 ASHRAE 62.2-2010) who had a post-Wx visit less than 6 months after Wx due to the time period
mismatch.
d
Possible responses to four strength and difficulties questions (well-behaved; worried; unhappy, depressed or tearful; and good attention span) were 0=not
true, 1=sometimes true, and 2=often true. The four responses were summed to yield a total score ranging from zero to 8, with higher scores indicating worse
condition.
e
CMH test that there was a change in the percentage or mean score from Pre- to Post-Wx
f
CMH test that the change in the percentage or mean score from Pre- to Post-Wx was different between the two groups

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Table 8. Housing characteristics
Characteristic
ASHRAE 62-1989 ASHRAE 62.2-2010
Pb
N=39 N=43
Housing Type (#/%)
Single Family Detached 39 (100%) 42 (98%) 1.000
Single Family Attached 0 1 (2%)
Number of Stories Above Grade (#/%)
1 Story 23 (59%) 26 (60%)
1.5 Stories 11 (28%) 8 (19%)
2 Stories 5 (13%) 9 (21%) 0.477
Garage (#/%)
No Garage 15 (38%) 13 (30%)
Attached, living space above 2 (5%) 3 (7%) 0.883
Attached, no living space above 7 (18%) 9 (2%)
Detached 15 (38%) 18 (42%)
Basement Present (#/%) 34 (87%) 35 (81%) 0.554
Basement occupieda 17 (50%) 21 (60%) 0.920
Basement has space(s) suitable for occupancya 19 (56%) 24 (68%) 0.764
Kitchen Exhaust Fan Present (#/%) 16 (41%) 19 (44%) 0.403
Bathroom Exhaust Fan Present in at least 1 bathroom (#/%) 27 (69%) 29 (67%) 1.000
Central Air Conditioning Present-integrated or stand-alone 29 (74%) 38 (88%) 0.152
(#/%)
Primary Heating System Type=Forced Air (#/%): 36 (92%) 38 (88%) 0.749
Heating System Fuel Type (#/%)
Natural gas 38 (97%) 42 (98%)
Oil/Kerosene 0 (0%) 1 (2%) 0.728
Electric 1 (3%) 0 (0%)
Approx. Building Age (years):
Minimum 34 4
Mean 59 56 0.637
Maximum 124 113

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ccepted Article Characteristic
ASHRAE 62-1989
N=39
ASHRAE 62.2-2010
N=43
Pb

Approx. Building Floor Area (ft2):

Minimum 768 608
Mean 1,298 1,301 0.978
Maximum 2,911 2,403
Approx. Baseline Building Leakage (ACH50):
Minimum 7.7 3.2
Mean 18.8 17.5 0.396
Maximum 33.5 39.3
ACH50=air changes per hour at 50 pascals
a
For basement occupancy questions, N=34 for ASHRAE 62-1989 and N=35 for ASHRAE 62.2-2010.
b
Test that there was a difference in the mean or distribution between the two groups

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Figure 1. Changes in reported indoor pest and smoke conditions (p values are tests to determine if the change in percent yes from baseline to
post-Wx is different for the two groups).

100%
92% 93%
87%
% Participants Reporting Housing Condition

90%
ASHRAE 62-1989 Baseline 77%
80% 76%
ASHRAE 62.2-1989 Post-Wx 73%
70% ASHRAE 62-2010 Baseline 65%
ASHRAE 62.2-2010 Post-Wx 60%
60%

50% 47%

38% 40%
40% 34%
31%
30% 26% 27%
22%
20% 14% 14% 14%
12%
6% 8% 8%
10% 5% 4%
3%
0% 0%
0%

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Figure 2. Changes in reported housing moisture and comfort conditions (p values shown are from tests to determine if the change in percent
yes from baseline to post-Wx is different for the two groups).

70%
65% 65%
63%
% Participants Reporting Housing Condition

60% ASHRAE 62-1989 Baseline

60% ASHRAE 62-1989 Post-Wx
ASHRAE-62.2-2010 Baseline
ASHRAE 62.2-2010 Post-Wx 50%
50% 46%
44%

40% 36%
34%
30% 30% 31% 30% 30% 30%
29%
30% 26% 27% 26%
23% 22%
20% 17% 18%
16%

10%

0%

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