A study of indoor carbon dioxide levels and sick leave among office workers
© Myatt et al; licensee BioMed Central Ltd. 2002
Received: 26 July 2002
Accepted: 22 October 2002
Published: 22 October 2002
A previous observational study detected a strong positive relationship between sick leave absences and carbon dioxide (CO2) concentrations in office buildings in the Boston area. The authors speculated that the observed association was due to a causal effect associated with low dilution ventilation, perhaps increased airborne transmission of respiratory infections. This study was undertaken to explore this association.
We conducted an intervention study of indoor CO2 levels and sick leave among hourly office workers employed by a large corporation. Outdoor air supply rates were adjusted periodically to increase the range of CO2 concentrations. We recorded indoor CO2 concentrations every 10 minutes and calculated a CO2 concentration differential as a measure of outdoor air supply per person by subtracting the 1–3 a.m. average CO2 concentration from the same-day 9 a.m. – 5 a.m. average concentration. The metric of CO2 differential was used as a surrogate for the concentration of exhaled breath and for potential exposure to human source airborne respiratory pathogens.
The weekly mean, workday, CO2 concentration differential ranged from 37 to 250 ppm with a peak CO2 concentration above background of 312 ppm as compared with the American Society of Heating, Refrigeration and Air-conditioning Engineers (ASHRAE) recommended maximum differential of 700 ppm. We determined the frequency of sick leave among 294 hourly workers scheduled to work approximately 49,804.2 days in the study areas using company records. We found no association between sick leave and CO2 differential
The CO2 differential was in the range of very low values, as compared with the ASHRAE recommended maximum differential of 700 ppm. Although no effect was found, this study was unable to test whether higher CO2 differentials may be associated with increased sick leave.
The majority of studies of indoor environmental quality and health outcomes focus primarily on the office environment and sick building syndrome symptoms or rare illnesses such as hypersensitivity pneumonitis. Very few studies have attempted to determine the effects of ventilation on short-term sick leave absences caused by respiratory infections.
Several studies have, however, made links between ventilation and respiratory illness [1–4]. Two of these studies were conducted in military settings. In a study at Army training centers, Brundage and colleagues detected significantly higher rates of febrile respiratory illness among building occupants housed in modern barracks with low outdoor air ventilation rates as compared to soldiers housed in older barracks with higher ventilation rates . In a study conducted during the Gulf War, Richards and his colleagues concluded that upper respiratory symptoms were more frequent in troops housed in air-conditioned barracks when compared to those that were housed in non-air-conditioned barracks, open warehouses or tents . In a hospital-based study, an outbreak of varicella virus was explained by airflow studies, which demonstrated the spread of airborne virus from an infected patient housed in an isolation room to 15 other patients . In a study conducted during a pneumococcal disease epidemic in a crowded jail, it was shown that attack rates were 95% higher in cells with the lowest volume of air supply per person .
Two studies have suggested a relationship between respiratory infections and office environments. In a study first published in 1960, Gwaltney and his colleagues conducted an extensive study at a large insurance company. Their results suggested that working adults were responsible for introducing 32% of the colds their families contracted [5–7]. More recently, a study of Finnish office workers suggested that workers who share offices are at increased risk of colds, although this study failed to conclude if the infections were transmitted as airborne infections or were transmitted by either large droplets or direct contact .
An underutilized method of evaluating building occupant health, which is particularly useful in office settings, is sick leave data. Sick leave data has been used for a variety of purposes such as to evaluate health promotion programs [9, 10], and to assess the efficacy of influenza vaccination . In general, a large fraction of sick leave is caused by respiratory illness [11–13]. In a study conducted by Nichol et al., upper respiratory infections accounted for approximately 65% of sick leave days among working adults . In a study of military aircrews, respiratory infections accounted for 70% of the total number of days the crews were grounded . In a study conducted on government employees in the United Kingdom, respiratory infections and gastroenteritis accounted for over half of all absences . Milton et al.  used sick leave data to identify an association between outdoor air supply levels and sick leave among office workers. The results indicated that lower levels of outdoor air supply in office buildings were associated with increased sick leave. This association was seen in both crude analyses of annual total absence and in an analysis of short-term absences. This association between ventilation and absences occurred at ventilation levels that have not often been associated with non-specific symptoms or with building related complaints . Because of this, the authors speculated that the observed association between indoor carbon dioxide (CO2) levels and sick leave might have been due to the increased spread of respiratory illness from either airborne spread of infection or increased susceptibility .
To determine whether a causal association could be confirmed, we conducted an experimental intervention study of indoor CO2 levels, used as a surrogate for the concentration of viable airborne microorganisms capable of causing a respiratory infection and sick leave among hourly office workers at Polaroid Corporation.
We conducted a blinded experimental intervention study to determine the effect indoor CO2 concentrations on sick leave absences among hourly office workers in selected areas of two office buildings. To increase the range of CO2 concentrations, the outdoor air supply dampers were adjusted to fixed positions that alternately reduced or increased the outdoor air supply. We attempted to increase the outdoor air supply only during periods in which the economizer function of the heating, ventilation and air-conditioning (HVAC) units would generally decrease the amount of outdoor air, such as during the heating and cooling seasons of summer and winter. In general, we tried to obtain CO2 concentrations in the range of 100–250 ppm above background levels during high ventilation intervention cycles and 350–500 ppm above background in low ventilation intervention cycles. All CO2 concentrations were less than the American Society of Heating, Refrigerating, and Air-Conditioning Engineers (ASHRAE) guidelines. Each intervention cycle lasted approximately three months. The study design was reviewed and approved by the Harvard School of Public Health Human Subjects Committee.
Office buildings and study population
Type of HVACb
Number of HVAC units serving study area
Floor Area (ft2)
Average Study Area Populationc
Ventilation and CO2measurements
To alter the levels of fresh air entering the buildings, the dampers on the air intakes were locked into fixed positions at each cycle of the intervention. To determine the air changes per hour in the buildings, we conducted tracer gas tests periodically. Sulfur hexafluoride (SF6) was used to generate a tracer gas decay curve. We injected SF6 into the fresh air plenum, followed by measurements in work areas and in the main return air duct with photoacoustic gas monitors (Bruel & Kjaer, Naerum, Denmark) with a SF6 filter (Model 1302).
Carbon dioxide concentrations in the study areas were measured once every 10 min with Vaisala monitors (model GMD20, Woburn, Massachusetts) attached to data loggers (HOBO H08-004-02, Onset Computer Corp., Bourne, MA). We calibrated each monitor with three known CO2 concentrations covering the range of 0–1000 ppm at least once per intervention cycle. We placed at least two centrally located monitors in each study area approximately 1 1/2 m above the floor. In addition, we located monitors out of doors on the roofs of study buildings.
Our primary exposure measure was the CO2 concentration above background in each building. This CO2 differential is used as a marker for the amount of air that has been previously breathed by building occupants. Rebreathed air potentially contains respiratory pathogens from infectious occupants. To determine the differential, we first averaged the workday (9 a.m. to 5 p.m.) CO2 concentration and subtracted the average CO2 concentration 1 a.m. – 3 a.m. measured on the same date by the same monitor. The 1 a.m. – 3 a.m. concentration measured by the same monitor was used rather than the outdoor CO2 concentration because the CO2 monitors tend to exhibit baseline drift. The average CO2 differential for the day was computed as the average across all monitors in the study area. We then averaged the daily CO2 differentials to compute a weekly average CO2 concentration differential.
Bioaerosol and particulate sampling
We sampled for airborne endotoxin and particulate in each building during each intervention cycle. Samples were collected on 37 mm diameter 0.4-μm pore diameter polycarbonate membrane filters (Whatman Nucleopore Filtration Products, Clifton, New Jersey) in closed face polystyrene cassettes (Millipore, Bedford, Massachusetts) at 4 liters per minute (l/min) using sampling pumps in acoustic foam insulated boxes. We extracted the filters in phosphate triethylamine buffer (pH 7.5) and assayed the filter extracts for endotoxin levels using the kinetic limulus assay with resistant-parallel-line estimation (KLARE) method [16, 17]. Endotoxin levels are reported as endotoxin units per cubic meter of air (EU/m3). Particulate samples were collected with Harvard Impactors  on 41 mm diameter 2.0-μm Teflo filters (Pall Gelman, Ann Arbor, Michigan) at 4 l/min. Both endotoxin and PM2.5 samples were collected for three consecutive days during working hours (9 a.m. to 5 p.m.) from the breathing zone of seated building occupants in the same location during each sampling period. Sampling took place over two weeks. In addition, we inspected each building for possible bioaerosol sources prior to its entry into the study, and again periodically throughout the study. We conducted a thorough building walk-through, looking at the building exterior and surroundings, air intakes, HVAC system, mechanical rooms, occupied space, storage areas, and any other areas, which might contain bioaerosol reservoirs. Special attention was given to air handling units and any other areas where excessive moisture is likely to accumulate.
Hourly attendance and demographic data for the study were collected using corporate databases. The Information Technology Department provided attendance data from the payroll records for hourly employees. Workers in the hourly payroll system completed weekly time cards that contained information on hours worked and time claimed for various leave categories including sick time, vacation, and personal leave. Demographic data was provided from the Human Resources Department all-employees database. Available demographic variables included employee ID number, seniority information (start, termination, retirement dates, etc.), race, gender, age, disability, and various job and departmental classifications. Final analytic data sets were produced with one record per week per hourly employee, with demographic data appended to each record.
We analyzed the relationship between CO2 exposure in the previous week and absence in the current week using a generalized additive mixed model  with a logit link. A model employing continuous exposure was chosen a priori over a simple model categorizing intervention intervals as high and low outdoor air supply because a continuous model with appropriate lags does not require elimination of data from wash-out periods at the start of each interval, and allows for differences between successive high (or low) interventions. The model used extends multiple logistic regression with an estimated "over-dispersion parameter" in two ways . First it allows the relationship between the covariates and input to the logit link to follow a smooth, not necessarily linear curve. The specific shape of the curve is modeled with a spline, a flexible model that essentially allows the data to determine the shape of the relationship. This feature of the model is necessary in our study since there is a markedly nonlinear relationship between CO2 exposure and the logit of absence probability. The second way this model extends multiple logistic regression is that it accounts for the correlation within the repeated measures on individuals using individual specific random effects . As discussed in Ruppert et al we estimate the parameters in this model using the pseudo-likelihood method implemented by the SAS macro GLIMMIX .
Characteristics of study population
Total Hourly Workers
Mean Age (SD)
Total Hours Scheduled
Total Sick Hours
Weekly Average Sick Leave Rate (hrs sick/ hrs scheduled) (SD)
Carbon dioxide concentration differentials1(ppm)
Maximum Daily Peak Differential
Daily Average Differential (ppm)
Weekly Average Differential (ppm)
Average CO2 differential, air changes per hour and sick leave rates for each intervention period
Outdoor Air Rate
Average CO2 Differential during day of SF6 test
CO2 Differential (ppm) during period during day of SF6 test
Sick Leave Rate (sick hrs/scheduled hrs)
Jan 2000 – April 2000
April 2000 – June 2000
July 2000 – Oct 2000
Nov 2000 – March 2001
March 2001 – May 2001
May 2001 – June 2001
Nov 2000 – Dec 2000
Dec 2000 – Feb 2001
March 2001 – May 2001
May 2001 – June 2001
Airborne endotoxin and particulates (PM2.5)
Outdoor Air Rate
No. Samples Collected
Mean (EU/m3) (SD)
No. Samples Collected
Mean (μg/m3) (SD)
Logistic generalized additive mixed models
Building 1 Logistic Model
p-value (2 sided test)
Sb 2 = 1.02a
Se 2 = 0.65b
Building 2 Logistic Model
p-value (2 sided test)
Sb 2 = 2.19a
Se 2 = 0.51b
In this intervention study of sick leave absences among hourly employees at Polaroid Corporation offices in suburban Boston, Massachusetts, we did not find a consistent positive relationship between indoor CO2 concentrations and sick leave. This result is in contrast to the results of our earlier observational study at Polaroid, which found a significant association of outdoor air supply rates and sick leave . In the earlier study, we used a larger number of work areas (115) including areas with lower ventilation and higher CO2 concentrations than were available for this intervention study. However, the previous study relied on a small number of CO2 measurements and primarily used expert judgment, of an industrial hygienist blinded to absence rates, to assign outdoor air supply rates to buildings. Thus, the intervention study was undertaken to confirm and extend the earlier findings.
In the earlier study, estimated outdoor air supply rates ranged from 12–24 liters per second (l/s) per person. In the current study, we can calculate the outdoor air supply rates if we assume a steady state CO2 concentration in the study buildings, although this assumption is questionable. Using the steady state equation relating CO2 levels and outdoor air supply rates, we calculate outdoor air supply rates that are nearly double that of the previous study, with the average daily outdoor supply rate of approximately 45 l/s per person for Building 1 and approximately 40 l/s per person for Building 2 as estimated from average CO2 concentrations. We attempted to control indoor CO2 concentrations by adjusting the supply of outside air supply, but the buildings available for the intervention study had an excess of ventilation capacity relative to the volume of office space and number of office workers. While these characteristics were advantageous for obtaining low CO2 concentrations relative to background, it was difficult to increase the concentrations of CO2 substantially above background. ASHRAE standards allow for up to 700 ppm CO2 above background in office buildings , while the maximum CO2 concentration above background in our buildings was 312 ppm; the average was less than half that.
This study showed that at high outdoor air supply rates sufficient to give weekly average indoor CO2 concentrations in the range of 50 to 200 ppm above background, sick leave is not associated with outdoor air supply rates. However, this study does not address the question of whether outdoor air supply rates resulting in CO2 concentrations between 200 and 700 ppm above background can be experimentally shown to drive changes in sick leave rates as suggested by observational data. While this result is of interest to large, highly ventilated corporate offices, it cannot be extrapolated to buildings with lower rates of outdoor air supply.
Air changes per hour
American Society of Heating Refrigeration, and Air-Conditioning Engineers
- HVAC Heating:
Ventilation and Air-conditioning
Kinetic limulus assay with resistant-parallel-line estimation
This work was supported by National Institute of Occupational Safety and Health, Grant number OH03694 and by National Institute of Environmental Health Sciences Center Grant 2P30ES00002. The National Institute Health's Training Program in Environmental Health Sciences number 2T32ES07155 supported Dr. Myatt.
- Leclair JM, Zaia JA, Levin MJ, Congdon RG, Goldmann DA: Airborne transmission of chickenpox in a hospital. N Engl J Med. 1980, 302: 450-453.View ArticleGoogle Scholar
- Brundage JF, Scott RM, Lednar WM, Smith DW, Miller RN: Building-associated risk of febrile acute respiratory diseases in Army trainees. JAMA. 1988, 259: 2108-2112. 10.1001/jama.259.14.2108.View ArticleGoogle Scholar
- Richards AL, Hyams KC, Watts DM, Rozmajzl PJ, Woody JN, Merrell BR: Respiratory disease among military personnel in Saudi Arabia during Operation Desert Shield. Am J Public Health. 1993, 83: 1326-1329.View ArticleGoogle Scholar
- Hoge CW, Reichler MR, Dominguez EA, Bremer JC, Mastro TD, Hendricks KA, et al: An epidemic of pneumococcal disease in an overcrowded, inadequately ventilated jail. N Engl J Med. 1994, 331: 643-648. 10.1056/NEJM199409083311004.View ArticleGoogle Scholar
- Gwaltney JM, Hendley JO, Simon G, Jordan WS: Rhinovirus infections in an industrial population. I. The occurrence of illness. N Engl J Med. 1966, 275: 1261-1268.View ArticleGoogle Scholar
- Gwaltney JM, Hendley JO, Simon G, Jordan WS: Rhinovirus infections in an industrial population. 3. Number and prevalence of serotypes. Am J Epidemiol. 1968, 87: 158-166.Google Scholar
- Hendley JO, Gwaltney JM, Jordan WS: Rhinovirus infections in an industrial population. IV. Infections within families of employees during two fall peaks of respiratory illness. Am J Epidemiol. 1969, 89: 184-196.Google Scholar
- Jaakkola J, Heinonen O: Shared office space and the risk of the common cold. Eur J Epidemiol. 1995, 11: 213-216.View ArticleGoogle Scholar
- Jeffery RW, Forster JL, Dunn BV, French SA, McGovern PG, Lando HA: Effects of work-site health promotion on illness-related absenteeism. J Occ Med. 1993, 35: 1142-1146.View ArticleGoogle Scholar
- Golaszewski T, Snow D, Lynch W, Yen L, Solomita D: A benefit-to-cost analysis of a work-site health promotion program. J Occ Med. 1992, 34: 1164-1172.Google Scholar
- Nichol KL, Lind A, Margolis KL, Murdoch M, McFadden R, Hauge M, et al: The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med. 1995, 333: 889-893. 10.1056/NEJM199510053331401.View ArticleGoogle Scholar
- Bendrick GA: Seasonal variation of grounding rates among B-52H aircrew. Mil Med. 1998, 163: 692-694.Google Scholar
- Feeney A, North F, Head J, Canner R, Marmot M: Socioeconomic and sex differentials in reason for sickness absence from the Whitehall II Study. Occ Environ Med. 1998, 55: 91-98.View ArticleGoogle Scholar
- Seppanen OA, Fisk WJ, Mendell MJ: Association of ventilation rates and CO2 concentrations with health and other responses in commercial and institutional buildings. Indoor Air. 1999, 9: 226-252.View ArticleGoogle Scholar
- Milton DK, Glencross PM, Walters MD: Risk of sick leave associated with outdoor air supply rate, humidification, and occupant complaints. Indoor Air. 2000, 10: 212-221. 10.1034/j.1600-0668.2000.010004212.x.View ArticleGoogle Scholar
- Milton DK, Feldman HA, Neuberg DS, Bruckner RJ, Greaves IA: Environmental endotoxin measurement: the kinetic Limulus assay with resistant-parallel-line estimation. Environ Res. 1992, 57: 212-230.View ArticleGoogle Scholar
- Milton DK, Johnson DK, Park J-H: Environmental endotoxin measurement: interference with limulus assay and relationship of airborne and settled dust endotoxin in homes. J Aller Clin Immunol. 1997, 99: S405-Google Scholar
- Marple VA, Rubow KL, Turner W, Spengler JD: Low flow rate sharp cut impactors for indoor air sampling: design and calibration. JAPCA. 1987, 37: 1303-1307.View ArticleGoogle Scholar
- Hastie T, Tibshirani R: Generalized Additive Models, ed. New York, CRC. 1990Google Scholar
- McCullagh P, Nelder J: Generalized Linear Models. New York, CRC. 1989, 2Google Scholar
- McCulloch C, Searle S: Generalized, Linear, and Mixed Models. New York, Wiley. 2001Google Scholar
- Ruppert D, Wand M, Carroll R: Semi-Parametric Regression Modelling. Forthcoming. 2002Google Scholar
- Wolfinger R, O'Connell M: Generalized Linear Mixed Models: A Pseudo-Likelihood Approach. J Stat Comput Simul. 1993, 48: 233-243.View ArticleGoogle Scholar
- American Society of Heating Refrigeration and Air Conditioning, Engineers: ANSI/ASHRAE Standard 62–1999: Ventilation for acceptable indoor air quality. Atlanta. 1999Google Scholar
- The pre-publication history for this paper can be accessed here:http://www.biomedcentral.com/content/backmatter/1476-069X-1-3-b1.pdf
This article is published under license to BioMed Central Ltd. This is an Open Access article: verbatim copying and redistribution of this article are permitted in all media for any purpose, provided this notice is preserved along with the article's original URL.