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Symptoms of illness attributed to a building

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Medical condition

Sick building syndrome
Specialty	Environmental medicine, immunology

Sick building syndrome (SBS) is a condition in which people develop symptoms of illness or become infected with chronic disease from the building in which they work or reside.^[1] In scientific literature, SBS is also known as building-related illness (BRI), building-related symptoms (BRS), or idiopathic environmental intolerance (IEI).

The main identifying observation is an increased incidence of complaints of such symptoms as headache, eye, nose, and throat irritation, fatigue, dizziness, and nausea. The 1989 Oxford English Dictionary defines SBS in that way.^[2] The World Health Organization created a 484-page tome on indoor air quality 1984, when SBS was attributed only to non-organic causes, and suggested that the book might form a basis for legislation or litigation.^[3]

The outbreaks may or may not be a direct result of inadequate or inappropriate cleaning.^[2] SBS has also been used to describe staff concerns in post-war buildings with faulty building aerodynamics, construction materials, construction process, and maintenance.^[2] Some symptoms tend to increase in severity with the time people spend in the building, often improving or even disappearing when people are away from the building.^[2][4] The term SBS is also used interchangeably with "building-related symptoms", which orients the name of the condition around patients' symptoms rather than a "sick" building.^[5]

Attempts have been made to connect sick building syndrome to various causes, such as contaminants produced by outgassing of some building materials, volatile organic compounds (VOC), improper exhaust ventilation of ozone (produced by the operation of some office machines), light industrial chemicals used within, and insufficient fresh-air intake or air filtration (see "Minimum efficiency reporting value").^[2] Sick building syndrome has also been attributed to heating, ventilation, and air conditioning (HVAC) systems, an attribution about which there are inconsistent findings.^[6]

Signs and symptoms

[edit]

Human exposure to aerosols has a variety of adverse health effects.^[7] Building occupants complain of symptoms such as sensory irritation of the eyes, nose, or throat; neurotoxic or general health problems; skin irritation; nonspecific hypersensitivity reactions; infectious diseases;^[8] and odor and taste sensations.^[9] Poor lighting has caused general malaise.^[10]

Extrinsic allergic alveolitis has been associated with the presence of fungi and bacteria in the moist air of residential houses and commercial offices.^[11] A study in 2017 correlated several inflammatory diseases of the respiratory tract with objective evidence of damp-caused damage in homes.^[12]

The WHO has classified the reported symptoms into broad categories, including mucous-membrane irritation (eye, nose, and throat irritation), neurotoxic effects (headaches, fatigue, and irritability), asthma and asthma-like symptoms (chest tightness and wheezing), skin dryness and irritation, and gastrointestinal complaints.^[13]

Several sick occupants may report individual symptoms that do not seem connected. The key to discovery is the increased incidence of illnesses in general with onset or exacerbation in a short period, usually weeks. In most cases, SBS symptoms are relieved soon after the occupants leave the particular room or zone.^[14] However, there can be lingering effects of various neurotoxins, which may not clear up when the occupant leaves the building. In some cases, including those of sensitive people, there are long-term health effects.^[15]

Cause

[edit]

ASHRAE has recognized that polluted urban air, designated within the United States Environmental Protection Agency (EPA)'s air quality ratings as unacceptable, requires the installation of treatment such as filtration for which the HVAC practitioners generally apply carbon-impregnated filters and their likes. Different toxins will aggravate the human body in different ways. Some people are more allergic to mold, while others are highly sensitive to dust. Inadequate ventilation will exaggerate small problems (such as deteriorating fiberglass insulation or cooking fumes) into a much more serious indoor air quality problem.^[10]

Common products such as paint, insulation, rigid foam, particle board, plywood, duct liners, exhaust fumes and other chemical contaminants from indoor or outdoor sources, and biological contaminants can be trapped inside by the HVAC AC system. As this air is recycled using fan coils the overall oxygenation ratio drops and becomes harmful. When combined with other stress factors such as traffic noise and poor lighting, inhabitants of buildings located in a polluted urban area can quickly become ill as their immune system is overwhelmed.^[10]

Certain VOCs, considered toxic chemical contaminants to humans, are used as adhesives in many common building construction products. These aromatic carbon rings / VOCs can cause acute and chronic health effects in the occupants of a building, including cancer, paralysis, lung failure, and others. Bacterial spores, fungal spores, mold spores, pollen, and viruses are types of biological contaminants and can all cause allergic reactions or illness described as SBS. In addition, pollution from outdoors, such as motor vehicle exhaust, can enter buildings, worsen indoor air quality, and increase the indoor concentration of carbon monoxide and carbon dioxide.^[16] Adult SBS symptoms were associated with a history of allergic rhinitis, eczema and asthma.^[17]

A 2015 study concerning the association of SBS and indoor air pollutants in office buildings in Iran found that, as carbon dioxide increased in a building, nausea, headaches, nasal irritation, dyspnea, and throat dryness also rose.^[10] Some work conditions have been correlated with specific symptoms: brighter light, for example was significantly related to skin dryness, eye pain, and malaise.^[10] Higher temperature is correlated with sneezing, skin redness, itchy eyes, and headache; lower relative humidity has been associated with sneezing, skin redness, and eye pain.^[10]

In 1973, in response to the oil crisis and conservation concerns, ASHRAE Standards 62-73 and 62-81 reduced required ventilation from 10 cubic feet per minute (4.7 L/s) per person to 5 cubic feet per minute (2.4 L/s) per person, but this was found to be a contributing factor to sick building syndrome.^[18] As of the 2016 revision, ASHRAE ventilation standards call for 5 to 10 cubic feet per minute of ventilation per occupant (depending on the occupancy type) in addition to ventilation based on the zone floor area delivered to the breathing zone.^[19]

Workplace

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Excessive work stress or dissatisfaction, poor interpersonal relationships and poor communication are often seen to be associated with SBS, recent^[when?] studies show that a combination of environmental sensitivity and stress can greatly contribute to sick building syndrome.^{[15][citation needed]}

Greater effects were found with features of the psycho-social work environment including high job demands and low support. The report concluded that the physical environment of office buildings appears to be less important than features of the psycho-social work environment in explaining differences in the prevalence of symptoms. However, there is still a relationship between sick building syndrome and symptoms of workers regardless of workplace stress.^[20]

Specific work-related stressors are related with specific SBS symptoms. Workload and work conflict are significantly associated with general symptoms (headache, abnormal tiredness, sensation of cold or nausea). While crowded workspaces and low work satisfaction are associated with upper respiratory symptoms.^[21] Work productivity has been associated with ventilation rates, a contributing factor to SBS, and there's a significant increase in production as ventilation rates increase, by 1.7% for every two-fold increase of ventilation rate.^[22] Printer effluent, released into the office air as ultra-fine particles (UFPs) as toner is burned during the printing process, may lead to certain SBS symptoms.^[23][24] Printer effluent may contain a variety of toxins to which a subset of office workers are sensitive, triggering SBS symptoms.^[25]

Specific careers are also associated with specific SBS symptoms. Transport, communication, healthcare, and social workers have highest prevalence of general symptoms. Skin symptoms such as eczema, itching, and rashes on hands and face are associated with technical work. Forestry, agriculture, and sales workers have the lowest rates of sick building syndrome symptoms.^[26]

From the assessment done by Fisk and Mudarri, 21% of asthma cases in the United States were caused by wet environments with mold that exist in all indoor environments, such as schools, office buildings, houses and apartments. Fisk and Berkeley Laboratory colleagues also found that the exposure to the mold increases the chances of respiratory issues by 30 to 50 percent.^[27] Additionally, studies showing that health effects with dampness and mold in indoor environments found that increased risk of adverse health effects occurs with dampness or visible mold environments.^[28]

Milton et al. determined the cost of sick leave specific for one business was an estimated $480 per employee, and about five days of sick leave per year could be attributed to low ventilation rates. When comparing low ventilation rate areas of the building to higher ventilation rate areas, the relative risk of short-term sick leave was 1.53 times greater in the low ventilation areas.^[29]

Home

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Sick building syndrome can be caused by one's home. Laminate flooring may release more SBS-causing chemicals than do stone, tile, and concrete floors.^[17] Recent redecorating and new furnishings within the last year are associated with increased symptoms; so are dampness and related factors, having pets, and cockroaches.^[17] Mosquitoes are related to more symptoms, but it is unclear whether the immediate cause of the symptoms is the mosquitoes or the repellents used against them.^[17]

Mold

[edit]

Main article: Mold health issues

Sick building syndrome may be associated with indoor mold or mycotoxin contamination. However, the attribution of sick building syndrome to mold is controversial and supported by little evidence.^[30][31][32]

Indoor temperature

[edit]

Indoor temperature under 18 °C (64 °F) has been shown to be associated with increased respiratory and cardiovascular diseases, increased blood levels, and increased hospitalization.^[33]

While sick building syndrome (SBS) encompasses a multitude of non-specific symptoms, building-related illness (BRI) comprises specific, diagnosable symptoms caused by certain agents (chemicals, bacteria, fungi, etc.). These can typically be identified, measured, and quantified.^[34] There are usually four causal agents in BRi: immunologic, infectious, toxic, and irritant.^[34] For instance, Legionnaire's disease, usually caused by Legionella pneumophila, involves a specific organism which could be ascertained through clinical findings as the source of contamination within a building.^[34]

• Reduction of time spent in the building
• If living in the building, moving to a new place
• Fixing any deteriorated paint or concrete deterioration
• Regular inspections to indicate for presence of mold or other toxins
• Adequate maintenance of all building mechanical systems
• Toxin-absorbing plants, such as sansevieria^{[35][36][37][38][39][40][41][excessive citations]}
• Roof shingle non-pressure cleaning for removal of algae, mold, and Gloeocapsa magma
• Using ozone to eliminate the many sources, such as VOCs, molds, mildews, bacteria, viruses, and even odors. However, numerous studies identify high-ozone shock treatment as ineffective despite commercial popularity and popular belief.
• Replacement of water-stained ceiling tiles and carpeting
• Only using paints, adhesives, solvents, and pesticides in well-ventilated areas or only using these pollutant sources during periods of non-occupancy
• Increasing the number of air exchanges; the American Society of Heating, Refrigeration and Air-Conditioning Engineers recommend a minimum of 8.4 air exchanges per 24-hour period
• Increased ventilation rates that are above the minimum guidelines^[22]
• Proper and frequent maintenance of HVAC systems
• UV-C light in the HVAC plenum
• Installation of HVAC air cleaning systems or devices to remove VOCs and bioeffluents (people odors)
• Central vacuums that completely remove all particles from the house including the ultrafine particles (UFPs) which are less than 0.1 μm
• Regular vacuuming with a HEPA filter vacuum cleaner to collect and retain 99.97% of particles down to and including 0.3 micrometers
• Placing bedding in sunshine, which is related to a study done in a high-humidity area where damp bedding was common and associated with SBS^[17]
• Lighting in the workplace should be designed to give individuals control, and be natural when possible^[42]
• Relocating office printers outside the air conditioning boundary, perhaps to another building
• Replacing current office printers with lower emission rate printers^[43]
• Identification and removal of products containing harmful ingredients

SBS, as a non-specific blanket term, does not have any specific cause or cure. Any known cure would be associated with the specific eventual disease that was cause by exposure to known contaminants. In all cases, alleviation consists of removing the affected person from the building associated. BRI, on the other hand, utilizes treatment appropriate for the contaminant identified within the building (e.g., antibiotics for Legionnaire's disease).^{[citation needed]}

Improving the indoor air quality (IAQ) of a particular building can attenuate, or even eliminate, the continued exposure to toxins. However, a Cochrane review of 12 mold and dampness remediation studies in private homes, workplaces and schools by two independent authors were deemed to be very low to moderate quality of evidence in reducing adult asthma symptoms and results were inconsistent among children.^[44] For the individual, the recovery may be a process involved with targeting the acute symptoms of a specific illness, as in the case of mold toxins.^[45] Treating various building-related illnesses is vital to the overall understanding of SBS. Careful analysis by certified building professionals and physicians can help to identify the exact cause of the BRI, and help to illustrate a causal path to infection. With this knowledge one can, theoretically, remediate a building of contaminants and rebuild the structure with new materials. Office BRI may more likely than not be explained by three events: "Wide range in the threshold of response in any population (susceptibility), a spectrum of response to any given agent, or variability in exposure within large office buildings."^[46]

Isolating any one of the three aspects of office BRI can be a great challenge, which is why those who find themselves with BRI should take three steps, history, examinations, and interventions. History describes the action of continually monitoring and recording the health of workers experiencing BRI, as well as obtaining records of previous building alterations or related activity. Examinations go hand in hand with monitoring employee health. This step is done by physically examining the entire workspace and evaluating possible threats to health status among employees. Interventions follow accordingly based on the results of the Examination and History report.^[46]

Some studies have found that women have higher reports of SBS symptoms than men.^[17][10] It is not entirely clear, however, if this is due to biological, social, or occupational factors.

A 2001 study published in the Journal Indoor Air, gathered 1464 office-working participants to increase the scientific understanding of gender differences under the Sick Building Syndrome phenomenon.^[47] Using questionnaires, ergonomic investigations, building evaluations, as well as physical, biological, and chemical variables, the investigators obtained results that compare with past studies of SBS and gender. The study team found that across most test variables, prevalence rates were different in most areas, but there was also a deep stratification of working conditions between genders as well. For example, men's workplaces tend to be significantly larger and have all-around better job characteristics. Secondly, there was a noticeable difference in reporting rates, specifically that women have higher rates of reporting roughly 20% higher than men. This information was similar to that found in previous studies, thus indicating a potential difference in willingness to report.^[47]

There might be a gender difference in reporting rates of sick building syndrome, because women tend to report more symptoms than men do. Along with this, some studies have found that women have a more responsive immune system and are more prone to mucosal dryness and facial erythema. Also, women are alleged by some to be more exposed to indoor environmental factors because they have a greater tendency to have clerical jobs, wherein they are exposed to unique office equipment and materials (example: blueprint machines, toner-based printers), whereas men often have jobs based outside of offices.^[48]

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In the late 1970s, it was noted that nonspecific symptoms were reported by tenants in newly constructed homes, offices, and nurseries. In media it was called "office illness". The term "sick building syndrome" was coined by the WHO in 1986, when they also estimated that 10–30% of newly built office buildings in the West had indoor air problems. Early Danish and British studies reported symptoms.

Poor indoor environments attracted attention. The Swedish allergy study (SOU 1989:76) designated "sick building" as a cause of the allergy epidemic as was feared. In the 1990s, therefore, extensive research into "sick building" was carried out. Various physical and chemical factors in the buildings were examined on a broad front.

The problem was highlighted increasingly in media and was described as a "ticking time bomb". Many studies were performed in individual buildings.

In the 1990s "sick buildings" were contrasted against "healthy buildings". The chemical contents of building materials were highlighted. Many building material manufacturers were actively working to gain control of the chemical content and to replace criticized additives. The ventilation industry advocated above all more well-functioning ventilation. Others perceived ecological construction, natural materials, and simple techniques as a solution.

At the end of the 1990s came an increased distrust of the concept of "sick building". A dissertation at the Karolinska Institute in Stockholm 1999 questioned the methodology of previous research, and a Danish study from 2005 showed these flaws experimentally. It was suggested that sick building syndrome was not really a coherent syndrome and was not a disease to be individually diagnosed, but a collection of as many as a dozen semi-related diseases. In 2006 the Swedish National Board of Health and Welfare recommended in the medical journal Läkartidningen that "sick building syndrome" should not be used as a clinical diagnosis. Thereafter, it has become increasingly less common to use terms such as sick buildings and sick building syndrome in research. However, the concept remains alive in popular culture and is used to designate the set of symptoms related to poor home or work environment engineering. Sick building is therefore an expression used especially in the context of workplace health.

Sick building syndrome made a rapid journey from media to courtroom where professional engineers and architects became named defendants and were represented by their respective professional practice insurers. Proceedings invariably relied on expert witnesses, medical and technical experts along with building managers, contractors and manufacturers of finishes and furnishings, testifying as to cause and effect. Most of these actions resulted in sealed settlement agreements, none of these being dramatic. The insurers needed a defense based upon Standards of Professional Practice to meet a court decision that declared that in a modern, essentially sealed building, the HVAC systems must produce breathing air for suitable human consumption. ASHRAE (American Society of Heating, Refrigeration and Air Conditioning Engineers, currently with over 50,000 international members) undertook the task of codifying its indoor air quality (IAQ) standard.

ASHRAE empirical research determined that "acceptability" was a function of outdoor (fresh air) ventilation rate and used carbon dioxide as an accurate measurement of occupant presence and activity. Building odors and contaminants would be suitably controlled by this dilution methodology. ASHRAE codified a level of 1,000 ppm of carbon dioxide and specified the use of widely available sense-and-control equipment to assure compliance. The 1989 issue of ASHRAE 62.1-1989 published the whys and wherefores and overrode the 1981 requirements that were aimed at a ventilation level of 5,000 ppm of carbon dioxide (the OSHA workplace limit), federally set to minimize HVAC system energy consumption. This apparently ended the SBS epidemic.

Over time, building materials changed with respect to emissions potential. Smoking vanished and dramatic improvements in ambient air quality, coupled with code compliant ventilation and maintenance, per ASHRAE standards have all contributed to the acceptability of the indoor air environment.^[49][50]

• Aerotoxic syndrome
• Air purifier
• Asthmagen
• Cleanroom
• Electromagnetic hypersensitivity
• Havana syndrome
• Healthy building
• Indoor air quality
• Lead paint
• Multiple chemical sensitivity
• NASA Clean Air Study
• Nosocomial infection
• Particulates
• Power tools
• Renovation
• Somatization disorder
• Fan death

• Martín-Gil J., Yanguas M. C., San José J. F., Rey-Martínez and Martín-Gil F. J. "Outcomes of research into a sick hospital". Hospital Management International, 1997, pp. 80–82. Sterling Publications Limited.
• Åke Thörn, The Emergence and preservation of sick building syndrome, KI 1999.
• Charlotte Brauer, The sick building syndrome revisited, Copenhagen 2005.
• Michelle Murphy, Sick Building Syndrome and the Problem of Uncertainty, 2006.
• Johan Carlson, "Gemensam förklaringsmodell för sjukdomar kopplade till inomhusmiljön finns inte" [Unified explanation for diseases related to indoor environment not found]. Läkartidningen 2006/12.
• Bulletin of the Transilvania University of BraÅŸov, Series I: Engineering Sciences • Vol. 5 (54) No. 1 2012 "Impact of Indoor Environment Quality on Sick Building Syndrome in Indian Leed Certified Buildings". by Jagannathan Mohan

• Best Practices for Indoor Air Quality when Remodeling Your Home, US EPA
• Renovation and Repair, Part of Indoor Air Quality Design Tools for Schools, US EPA
• Addressing Indoor Environmental Concerns During Remodeling, US EPA
• Dust FAQs, UK HSE Archived 2023-03-20 at the Wayback Machine
• CCOHS: Welding - Fumes And Gases | Health Effect of Welding Fumes

Satisfaction with the thermal environment

This article is about comfort zones in building construction. For other uses, see Comfort zone (disambiguation).

Thermal comfort is the condition of mind that expresses subjective satisfaction with the thermal environment.^[1] The human body can be viewed as a heat engine where food is the input energy. The human body will release excess heat into the environment, so the body can continue to operate. The heat transfer is proportional to temperature difference. In cold environments, the body loses more heat to the environment and in hot environments the body does not release enough heat. Both the hot and cold scenarios lead to discomfort.^[2] Maintaining this standard of thermal comfort for occupants of buildings or other enclosures is one of the important goals of HVAC (heating, ventilation, and air conditioning) design engineers.

Thermal neutrality is maintained when the heat generated by human metabolism is allowed to dissipate, thus maintaining thermal equilibrium with the surroundings. The main factors that influence thermal neutrality are those that determine heat gain and loss, namely metabolic rate, clothing insulation, air temperature, mean radiant temperature, air speed and relative humidity. Psychological parameters, such as individual expectations, and physiological parameters also affect thermal neutrality.^[3] Neutral temperature is the temperature that can lead to thermal neutrality and it may vary greatly between individuals and depending on factors such as activity level, clothing, and humidity. People are highly sensitive to even small differences in environmental temperature. At 24 °C, a difference of 0.38 °C can be detected between the temperature of two rooms.^[4]

The Predicted Mean Vote (PMV) model stands among the most recognized thermal comfort models. It was developed using principles of heat balance and experimental data collected in a controlled climate chamber under steady state conditions.^[5] The adaptive model, on the other hand, was developed based on hundreds of field studies with the idea that occupants dynamically interact with their environment. Occupants control their thermal environment by means of clothing, operable windows, fans, personal heaters, and sun shades.^[3][6] The PMV model can be applied to air-conditioned buildings, while the adaptive model can be applied only to buildings where no mechanical systems have been installed.^[1] There is no consensus about which comfort model should be applied for buildings that are partially air-conditioned spatially or temporally.

Thermal comfort calculations in accordance with the ANSI/ASHRAE Standard 55,^[1] the ISO 7730 Standard^[7] and the EN 16798-1 Standard^[8] can be freely performed with either the CBE Thermal Comfort Tool for ASHRAE 55,^[9] with the Python package pythermalcomfort^[10] or with the R package comf.

Significance

[edit]

Satisfaction with the thermal environment is important because thermal conditions are potentially life-threatening for humans if the core body temperature reaches conditions of hyperthermia, above 37.5–38.3 °C (99.5–100.9 °F),^[11][12] or hypothermia, below 35.0 °C (95.0 °F).^[13] Buildings modify the conditions of the external environment and reduce the effort that the human body needs to do in order to stay stable at a normal human body temperature, important for the correct functioning of human physiological processes.

The Roman writer Vitruvius actually linked this purpose to the birth of architecture.^[14] David Linden also suggests that the reason why we associate tropical beaches with paradise is because in those environments is where human bodies need to do less metabolic effort to maintain their core temperature.^[15] Temperature not only supports human life; coolness and warmth have also become in different cultures a symbol of protection, community and even the sacred.^[16]

In building science studies, thermal comfort has been related to productivity and health. Office workers who are satisfied with their thermal environment are more productive.^[17][18] The combination of high temperature and high relative humidity reduces thermal comfort and indoor air quality.^[19]

Although a single static temperature can be comfortable, people are attracted by thermal changes, such as campfires and cool pools. Thermal pleasure is caused by varying thermal sensations from a state of unpleasantness to a state of pleasantness, and the scientific term for it is positive thermal alliesthesia.^[20] From a state of thermal neutrality or comfort any change will be perceived as unpleasant.^[21] This challenges the assumption that mechanically controlled buildings should deliver uniform temperatures and comfort, if it is at the cost of excluding thermal pleasure.^[22]

Influencing factors

[edit]

Since there are large variations from person to person in terms of physiological and psychological satisfaction, it is hard to find an optimal temperature for everyone in a given space. Laboratory and field data have been collected to define conditions that will be found comfortable for a specified percentage of occupants.^[1]

There are numerous factors that directly affect thermal comfort that can be grouped in two categories:

1. Personal factors – characteristics of the occupants such as metabolic rate and clothing level
2. Environmental factors – which are conditions of the thermal environment, specifically air temperature, mean radiant temperature, air speed and humidity

Even if all these factors may vary with time, standards usually refer to a steady state to study thermal comfort, just allowing limited temperature variations.

Personal factors

[edit]

Metabolic rate

[edit]

People have different metabolic rates that can fluctuate due to activity level and environmental conditions.^[23][24][25] ASHRAE 55-2017 defines metabolic rate as the rate of transformation of chemical energy into heat and mechanical work by metabolic activities of an individual, per unit of skin surface area.^{[1]: 3â€ÅÂÂÂÂÂÂ} 

Metabolic rate is expressed in units of met, equal to 58.2 W/m² (18.4 Btu/h·ft²). One met is equal to the energy produced per unit surface area of an average person seated at rest.

ASHRAE 55 provides a table of metabolic rates for a variety of activities. Some common values are 0.7 met for sleeping, 1.0 met for a seated and quiet position, 1.2–1.4 met for light activities standing, 2.0 met or more for activities that involve movement, walking, lifting heavy loads or operating machinery. For intermittent activity, the standard states that it is permissible to use a time-weighted average metabolic rate if individuals are performing activities that vary over a period of one hour or less. For longer periods, different metabolic rates must be considered.^[1]

According to ASHRAE Handbook of Fundamentals, estimating metabolic rates is complex, and for levels above 2 or 3 met – especially if there are various ways of performing such activities – the accuracy is low. Therefore, the standard is not applicable for activities with an average level higher than 2 met. Met values can also be determined more accurately than the tabulated ones, using an empirical equation that takes into account the rate of respiratory oxygen consumption and carbon dioxide production. Another physiological yet less accurate method is related to the heart rate, since there is a relationship between the latter and oxygen consumption.^[26]

The Compendium of Physical Activities is used by physicians to record physical activities. It has a different definition of met that is the ratio of the metabolic rate of the activity in question to a resting metabolic rate.^[27] As the formulation of the concept is different from the one that ASHRAE uses, these met values cannot be used directly in PMV calculations, but it opens up a new way of quantifying physical activities.

Food and drink habits may have an influence on metabolic rates, which indirectly influences thermal preferences. These effects may change depending on food and drink intake.^[28]

Body shape is another factor that affects metabolic rate and hence thermal comfort. Heat dissipation depends on body surface area. The surface area of an average person is 1.8 m² (19 ft²).^[1] A tall and skinny person has a larger surface-to-volume ratio, can dissipate heat more easily, and can tolerate higher temperatures more than a person with a rounded body shape.^[28]

The amount of thermal insulation worn by a person has a substantial impact on thermal comfort, because it influences the heat loss and consequently the thermal balance. Layers of insulating clothing prevent heat loss and can either help keep a person warm or lead to overheating. Generally, the thicker the garment is, the greater insulating ability it has. Depending on the type of material the clothing is made out of, air movement and relative humidity can decrease the insulating ability of the material.^[29][30]

1 clo is equal to 0.155 m²·K/W (0.88 °F·ft²·h/Btu). This corresponds to trousers, a long sleeved shirt, and a jacket. Clothing insulation values for other common ensembles or single garments can be found in ASHRAE 55.^[1]

Skin wetness is defined as "the proportion of the total skin surface area of the body covered with sweat".^[31] The wetness of skin in different areas also affects perceived thermal comfort. Humidity can increase wetness in different areas of the body, leading to a perception of discomfort. This is usually localized in different parts of the body, and local thermal comfort limits for skin wetness differ by locations of the body.^[32] The extremities are much more sensitive to thermal discomfort from wetness than the trunk of the body. Although local thermal discomfort can be caused by wetness, the thermal comfort of the whole body will not be affected by the wetness of certain parts.

The air temperature is the average temperature of the air surrounding the occupant, with respect to location and time. According to ASHRAE 55 standard, the spatial average takes into account the ankle, waist and head levels, which vary for seated or standing occupants. The temporal average is based on three-minutes intervals with at least 18 equally spaced points in time. Air temperature is measured with a dry-bulb thermometer and for this reason it is also known as dry-bulb temperature.

The radiant temperature is related to the amount of radiant heat transferred from a surface, and it depends on the material's ability to absorb or emit heat, or its emissivity. The mean radiant temperature depends on the temperatures and emissivities of the surrounding surfaces as well as the view factor, or the amount of the surface that is “seen” by the object. So the mean radiant temperature experienced by a person in a room with the sunlight streaming in varies based on how much of their body is in the sun.

Air speed is defined as the rate of air movement at a point, without regard to direction. According to ANSI/ASHRAE Standard 55, it is the average speed of the air surrounding a representative occupant, with respect to location and time. The spatial average is for three heights as defined for average air temperature. For an occupant moving in a space the sensors shall follow the movements of the occupant. The air speed is averaged over an interval not less than one and not greater than three minutes. Variations that occur over a period greater than three minutes shall be treated as multiple different air speeds.^[33]

Relative humidity (RH) is the ratio of the amount of water vapor in the air to the amount of water vapor that the air could hold at the specific temperature and pressure. While the human body has thermoreceptors in the skin that enable perception of temperature, relative humidity is detected indirectly. Sweating is an effective heat loss mechanism that relies on evaporation from the skin. However at high RH, the air has close to the maximum water vapor that it can hold, so evaporation, and therefore heat loss, is decreased. On the other hand, very dry environments (RH < 20–30%) are also uncomfortable because of their effect on the mucous membranes. The recommended level of indoor humidity is in the range of 30–60% in air conditioned buildings,^[34][35] but new standards such as the adaptive model allow lower and higher humidity, depending on the other factors involved in thermal comfort.

Recently, the effects of low relative humidity and high air velocity were tested on humans after bathing. Researchers found that low relative humidity engendered thermal discomfort as well as the sensation of dryness and itching. It is recommended to keep relative humidity levels higher in a bathroom than other rooms in the house for optimal conditions.^[36]

Various types of apparent temperature have been developed to combine air temperature and air humidity. For higher temperatures, there are quantitative scales, such as the heat index. For lower temperatures, a related interplay was identified only qualitatively:

• High humidity and low temperatures cause the air to feel chilly.^[37]
• Cold air with high relative humidity "feels" colder than dry air of the same temperature because high humidity in cold weather increases the conduction of heat from the body.^[38]

There has been controversy over why damp cold air feels colder than dry cold air. Some believe it is because when the humidity is high, our skin and clothing become moist and are better conductors of heat, so there is more cooling by conduction.^[39]

The influence of humidity can be exacerbated with the combined use of fans (forced convection cooling).^[40]

Many buildings use an HVAC unit to control their thermal environment. Other buildings are naturally ventilated (or would have cross ventilation) and do not rely on mechanical systems to provide thermal comfort. Depending on the climate, this can drastically reduce energy consumption. It is sometimes seen as a risk, though, since indoor temperatures can be too extreme if the building is poorly designed. Properly designed, naturally ventilated buildings keep indoor conditions within the range where opening windows and using fans in the summer, and wearing extra clothing in the winter, can keep people thermally comfortable.^[41]

There are several different models or indices that can be used to assess thermal comfort conditions indoors as described below.

Psychrometric Chart

Temperature-relative humidity chart

Two alternative representations of thermal comfort for the PMV/PPD method

The PMV/PPD model was developed by P.O. Fanger using heat-balance equations and empirical studies about skin temperature to define comfort. Standard thermal comfort surveys ask subjects about their thermal sensation on a seven-point scale from cold (−3) to hot (+3). Fanger's equations are used to calculate the predicted mean vote (PMV) of a group of subjects for a particular combination of air temperature, mean radiant temperature, relative humidity, air speed, metabolic rate, and clothing insulation.^[5] PMV equal to zero is representing thermal neutrality, and the comfort zone is defined by the combinations of the six parameters for which the PMV is within the recommended limits (−0.5 < PMV < +0.5).^[1] Although predicting the thermal sensation of a population is an important step in determining what conditions are comfortable, it is more useful to consider whether or not people will be satisfied. Fanger developed another equation to relate the PMV to the Predicted Percentage of Dissatisfied (PPD). This relation was based on studies that surveyed subjects in a chamber where the indoor conditions could be precisely controlled.^[5]

The PMV/PPD model is applied globally but does not directly take into account the adaptation mechanisms and outdoor thermal conditions.^[3][42][43]

ASHRAE Standard 55-2017 uses the PMV model to set the requirements for indoor thermal conditions. It requires that at least 80% of the occupants be satisfied.^[1]

The CBE Thermal Comfort Tool for ASHRAE 55^[9] allows users to input the six comfort parameters to determine whether a certain combination complies with ASHRAE 55. The results are displayed on a psychrometric or a temperature-relative humidity chart and indicate the ranges of temperature and relative humidity that will be comfortable with the given the values input for the remaining four parameters.^[44]

The PMV/PPD model has a low prediction accuracy.^[45] Using the world largest thermal comfort field survey database,^[46] the accuracy of PMV in predicting occupant's thermal sensation was only 34%, meaning that the thermal sensation is correctly predicted one out of three times. The PPD was overestimating subject's thermal unacceptability outside the thermal neutrality ranges (-1≤PMV≤1). The PMV/PPD accuracy varies strongly between ventilation strategies, building types and climates.^[45]

ASHRAE 55 2013 accounts for air speeds above 0.2 metres per second (0.66 ft/s) separately than the baseline model. Because air movement can provide direct cooling to people, particularly if they are not wearing much clothing, higher temperatures can be more comfortable than the PMV model predicts. Air speeds up to 0.8 m/s (2.6 ft/s) are allowed without local control, and 1.2 m/s is possible with local control. This elevated air movement increases the maximum temperature for an office space in the summer to 30 °C from 27.5 °C (86.0–81.5 °F).^[1]

"Virtual Energy for Thermal Comfort" is the amount of energy that will be required to make a non-air-conditioned building relatively as comfortable as one with air-conditioning. This is based on the assumption that the home will eventually install air-conditioning or heating.^[47] Passive design improves thermal comfort in a building, thus reducing demand for heating or cooling. In many developing countries, however, most occupants do not currently heat or cool, due to economic constraints, as well as climate conditions which border lines comfort conditions such as cold winter nights in Johannesburg (South Africa) or warm summer days in San Jose, Costa Rica. At the same time, as incomes rise, there is a strong tendency to introduce cooling and heating systems. If we recognize and reward passive design features that improve thermal comfort today, we diminish the risk of having to install HVAC systems in the future, or we at least ensure that such systems will be smaller and less frequently used. Or in case the heating or cooling system is not installed due to high cost, at least people should not suffer from discomfort indoors. To provide an example, in San Jose, Costa Rica, if a house were being designed with high level of glazing and small opening sizes, the internal temperature would easily rise above 30 °C (86 °F) and natural ventilation would not be enough to remove the internal heat gains and solar gains. This is why Virtual Energy for Comfort is important.

World Bank's assessment tool the EDGE software (Excellence in Design for Greater Efficiencies) illustrates the potential issues with discomfort in buildings and has created the concept of Virtual Energy for Comfort which provides for a way to present potential thermal discomfort. This approach is used to award for design solutions which improves thermal comfort even in a fully free running building. Despite the inclusion of requirements for overheating in CIBSE, overcooling has not been assessed. However, overcooling can be an issue, mainly in the developing world, for example in cities such as Lima (Peru), Bogota, and Delhi, where cooler indoor temperatures can occur frequently. This may be a new area for research and design guidance for reduction of discomfort.

ASHRAE 55-2017 defines the Cooling Effect (CE) at elevated air speed (above 0.2 metres per second (0.66 ft/s)) as the value that, when subtracted from both the air temperature and the mean radiant temperature, yields the same SET value under still air (0.1 m/s) as in the first SET calculation under elevated air speed.^[1]

$\displaystyle SET(t_a,t_r,v,met,clo,RH)=SET(t_a-CE,t_r-CE,v=0.1,met,clo,RH)$

The CE can be used to determine the PMV adjusted for an environment with elevated air speed using the adjusted temperature, the adjusted radiant temperature and still air (0.2 metres per second (0.66 ft/s)). Where the adjusted temperatures are equal to the original air and mean radiant temperatures minus the CE.

Avoiding local thermal discomfort, whether caused by a vertical air temperature difference between the feet and the head, by an asymmetric radiant field, by local convective cooling (draft), or by contact with a hot or cold floor, is essential to providing acceptable thermal comfort. People are generally more sensitive to local discomfort when their thermal sensation is cooler than neutral, while they are less sensitive to it when their body is warmer than neutral.^[33]

Large differences in the thermal radiation of the surfaces surrounding a person may cause local discomfort or reduce acceptance of the thermal conditions. ASHRAE Standard 55 sets limits on the allowable temperature differences between various surfaces. Because people are more sensitive to some asymmetries than others, for example that of a warm ceiling versus that of hot and cold vertical surfaces, the limits depend on which surfaces are involved. The ceiling is not allowed to be more than +5 °C (9.0 °F) warmer, whereas a wall may be up to +23 °C (41 °F) warmer than the other surfaces.^[1]

While air movement can be pleasant and provide comfort in some circumstances, it is sometimes unwanted and causes discomfort. This unwanted air movement is called "draft" and is most prevalent when the thermal sensation of the whole body is cool. People are most likely to feel a draft on uncovered body parts such as their head, neck, shoulders, ankles, feet, and legs, but the sensation also depends on the air speed, air temperature, activity, and clothing.^[1]

Floors that are too warm or too cool may cause discomfort, depending on footwear. ASHRAE 55 recommends that floor temperatures stay in the range of 19–29 °C (66–84 °F) in spaces where occupants will be wearing lightweight shoes.^[1]

Standard effective temperature (SET) is a model of human response to the thermal environment. Developed by A.P. Gagge and accepted by ASHRAE in 1986,^[48] it is also referred to as the Pierce Two-Node model.^[49] Its calculation is similar to PMV because it is a comprehensive comfort index based on heat-balance equations that incorporates the personal factors of clothing and metabolic rate. Its fundamental difference is it takes a two-node method to represent human physiology in measuring skin temperature and skin wettedness.^[48]

The SET index is defined as the equivalent dry bulb temperature of an isothermal environment at 50% relative humidity in which a subject, while wearing clothing standardized for activity concerned, would have the same heat stress (skin temperature) and thermoregulatory strain (skin wettedness) as in the actual test environment.^[48]

Research has tested the model against experimental data and found it tends to overestimate skin temperature and underestimate skin wettedness.^[49][50] Fountain and Huizenga (1997) developed a thermal sensation prediction tool that computes SET.^[51] The SET index can also be calculated using either the CBE Thermal Comfort Tool for ASHRAE 55,^[9] the Python package pythermalcomfort,^[10] or the R package comf.

The adaptive model is based on the idea that outdoor climate might be used as a proxy of indoor comfort because of a statistically significant correlation between them. The adaptive hypothesis predicts that contextual factors, such as having access to environmental controls, and past thermal history can influence building occupants' thermal expectations and preferences.^[3] Numerous researchers have conducted field studies worldwide in which they survey building occupants about their thermal comfort while taking simultaneous environmental measurements. Analyzing a database of results from 160 of these buildings revealed that occupants of naturally ventilated buildings accept and even prefer a wider range of temperatures than their counterparts in sealed, air-conditioned buildings because their preferred temperature depends on outdoor conditions.^[3] These results were incorporated in the ASHRAE 55-2004 standard as the adaptive comfort model. The adaptive chart relates indoor comfort temperature to prevailing outdoor temperature and defines zones of 80% and 90% satisfaction.^[1]

The ASHRAE-55 2010 Standard introduced the prevailing mean outdoor temperature as the input variable for the adaptive model. It is based on the arithmetic average of the mean daily outdoor temperatures over no fewer than 7 and no more than 30 sequential days prior to the day in question.^[1] It can also be calculated by weighting the temperatures with different coefficients, assigning increasing importance to the most recent temperatures. In case this weighting is used, there is no need to respect the upper limit for the subsequent days. In order to apply the adaptive model, there should be no mechanical cooling system for the space, occupants should be engaged in sedentary activities with metabolic rates of 1–1.3 met, and a prevailing mean temperature of 10–33.5 °C (50.0–92.3 °F).^[1]

This model applies especially to occupant-controlled, natural-conditioned spaces, where the outdoor climate can actually affect the indoor conditions and so the comfort zone. In fact, studies by de Dear and Brager showed that occupants in naturally ventilated buildings were tolerant of a wider range of temperatures.^[3] This is due to both behavioral and physiological adjustments, since there are different types of adaptive processes.^[52] ASHRAE Standard 55-2010 states that differences in recent thermal experiences, changes in clothing, availability of control options, and shifts in occupant expectations can change people's thermal responses.^[1]

Adaptive models of thermal comfort are implemented in other standards, such as European EN 15251 and ISO 7730 standard. While the exact derivation methods and results are slightly different from the ASHRAE 55 adaptive standard, they are substantially the same. A larger difference is in applicability. The ASHRAE adaptive standard only applies to buildings without mechanical cooling installed, while EN15251 can be applied to mixed-mode buildings, provided the system is not running.^[53]

There are basically three categories of thermal adaptation, namely: behavioral, physiological, and psychological.

An individual's comfort level in a given environment may change and adapt over time due to psychological factors. Subjective perception of thermal comfort may be influenced by the memory of previous experiences. Habituation takes place when repeated exposure moderates future expectations, and responses to sensory input. This is an important factor in explaining the difference between field observations and PMV predictions (based on the static model) in naturally ventilated buildings. In these buildings, the relationship with the outdoor temperatures has been twice as strong as predicted.^[3]

Psychological adaptation is subtly different in the static and adaptive models. Laboratory tests of the static model can identify and quantify non-heat transfer (psychological) factors that affect reported comfort. The adaptive model is limited to reporting differences (called psychological) between modeled and reported comfort.^{[citation needed]}

Thermal comfort as a "condition of mind" is defined in psychological terms. Among the factors that affect the condition of mind (in the laboratory) are a sense of control over the temperature, knowledge of the temperature and the appearance of the (test) environment. A thermal test chamber that appeared residential "felt" warmer than one which looked like the inside of a refrigerator.^[54]

The body has several thermal adjustment mechanisms to survive in drastic temperature environments. In a cold environment the body utilizes vasoconstriction; which reduces blood flow to the skin, skin temperature and heat dissipation. In a warm environment, vasodilation will increase blood flow to the skin, heat transport, and skin temperature and heat dissipation.^[55] If there is an imbalance despite the vasomotor adjustments listed above, in a warm environment sweat production will start and provide evaporative cooling. If this is insufficient, hyperthermia will set in, body temperature may reach 40 °C (104 °F), and heat stroke may occur. In a cold environment, shivering will start, involuntarily forcing the muscles to work and increasing the heat production by up to a factor of 10. If equilibrium is not restored, hypothermia can set in, which can be fatal.^[55] Long-term adjustments to extreme temperatures, of a few days to six months, may result in cardiovascular and endocrine adjustments. A hot climate may create increased blood volume, improving the effectiveness of vasodilation, enhanced performance of the sweat mechanism, and the readjustment of thermal preferences. In cold or underheated conditions, vasoconstriction can become permanent, resulting in decreased blood volume and increased body metabolic rate.^[55]

In naturally ventilated buildings, occupants take numerous actions to keep themselves comfortable when the indoor conditions drift towards discomfort. Operating windows and fans, adjusting blinds/shades, changing clothing, and consuming food and drinks are some of the common adaptive strategies. Among these, adjusting windows is the most common.^[56] Those occupants who take these sorts of actions tend to feel cooler at warmer temperatures than those who do not.^[57]

The behavioral actions significantly influence energy simulation inputs, and researchers are developing behavior models to improve the accuracy of simulation results. For example, there are many window-opening models that have been developed to date, but there is no consensus over the factors that trigger window opening.^[56]

People might adapt to seasonal heat by becoming more nocturnal, doing physical activity and even conducting business at night.

The thermal sensitivity of an individual is quantified by the descriptor F_S, which takes on higher values for individuals with lower tolerance to non-ideal thermal conditions.^[58] This group includes pregnant women, the disabled, as well as individuals whose age is below fourteen or above sixty, which is considered the adult range. Existing literature provides consistent evidence that sensitivity to hot and cold surfaces usually declines with age. There is also some evidence of a gradual reduction in the effectiveness of the body in thermo-regulation after the age of sixty.^[58] This is mainly due to a more sluggish response of the counteraction mechanisms in lower parts of the body that are used to maintain the core temperature of the body at ideal values.^[58] Seniors prefer warmer temperatures than young adults (76 vs 72 degrees F or 24.4 vs 22.2 Celsius).^[54]

Situational factors include the health, psychological, sociological, and vocational activities of the persons.

While thermal comfort preferences between sexes seem to be small, there are some average differences. Studies have found males on average report discomfort due to rises in temperature much earlier than females. Males on average also estimate higher levels of their sensation of discomfort than females. One recent study tested males and females in the same cotton clothing, performing mental jobs while using a dial vote to report their thermal comfort to the changing temperature.^[59] Many times, females preferred higher temperatures than males. But while females tend to be more sensitive to temperatures, males tend to be more sensitive to relative-humidity levels.^[60][61]

An extensive field study was carried out in naturally ventilated residential buildings in Kota Kinabalu, Sabah, Malaysia. This investigation explored the sexes thermal sensitivity to the indoor environment in non-air-conditioned residential buildings. Multiple hierarchical regression for categorical moderator was selected for data analysis; the result showed that as a group females were slightly more sensitive than males to the indoor air temperatures, whereas, under thermal neutrality, it was found that males and females have similar thermal sensation.^[62]

In different areas of the world, thermal comfort needs may vary based on climate. In China^[where?] the climate has hot humid summers and cold winters, causing a need for efficient thermal comfort. Energy conservation in relation to thermal comfort has become a large issue in China in the last several decades due to rapid economic and population growth.^[63] Researchers are now looking into ways to heat and cool buildings in China for lower costs and also with less harm to the environment.

In tropical areas of Brazil, urbanization is creating urban heat islands (UHI). These are urban areas that have risen over the thermal comfort limits due to a large influx of people and only drop within the comfortable range during the rainy season.^[64] Urban heat islands can occur over any urban city or built-up area with the correct conditions.^[65][66]

In the hot, humid region of Saudi Arabia, the issue of thermal comfort has been important in mosques, because they are very large open buildings that are used only intermittently (very busy for the noon prayer on Fridays) it is hard to ventilate them properly. The large size requires a large amount of ventilation, which requires a lot of energy since the buildings are used only for short periods of time. Temperature regulation in mosques is a challenge due to the intermittent demand, leading to many mosques being either too hot or too cold. The stack effect also comes into play due to their large size and creates a large layer of hot air above the people in the mosque. New designs have placed the ventilation systems lower in the buildings to provide more temperature control at ground level.^[67] New monitoring steps are also being taken to improve efficiency.^[68]

The concept of thermal comfort is closely related to thermal stress. This attempts to predict the impact of solar radiation, air movement, and humidity for military personnel undergoing training exercises or athletes during competitive events. Several thermal stress indices have been proposed, such as the Predicted Heat Strain (PHS) or the humidex.^[69] Generally, humans do not perform well under thermal stress. People's performances under thermal stress is about 11% lower than their performance at normal thermal wet conditions. Also, human performance in relation to thermal stress varies greatly by the type of task which the individual is completing. Some of the physiological effects of thermal heat stress include increased blood flow to the skin, sweating, and increased ventilation.^[70][71]

The PHS model, developed by the International Organization for Standardization (ISO) committee, allows the analytical evaluation of the thermal stress experienced by a working subject in a hot environment.^[72] It describes a method for predicting the sweat rate and the internal core temperature that the human body will develop in response to the working conditions. The PHS is calculated as a function of several physical parameters, consequently it makes it possible to determine which parameter or group of parameters should be modified, and to what extent, in order to reduce the risk of physiological strains. The PHS model does not predict the physiological response of an individual subject, but only considers standard subjects in good health and fit for the work they perform. The PHS can be determined using either the Python package pythermalcomfort^[10] or the R package comf.

ACGIH has established Action Limits and Threshold Limit Values for heat stress based upon the estimated metabolic rate of a worker and the environmental conditions the worker is subjected to.

This methodology has been adopted by the Occupational Safety and Health Administration (OSHA) as an effective method of assesing heat stress within workplaces.^[73]

The factors affecting thermal comfort were explored experimentally in the 1970s. Many of these studies led to the development and refinement of ASHRAE Standard 55 and were performed at Kansas State University by Ole Fanger and others. Perceived comfort was found to be a complex interaction of these variables. It was found that the majority of individuals would be satisfied by an ideal set of values. As the range of values deviated progressively from the ideal, fewer and fewer people were satisfied. This observation could be expressed statistically as the percent of individuals who expressed satisfaction by comfort conditions and the predicted mean vote (PMV). This approach was challenged by the adaptive comfort model, developed from the ASHRAE 884 project, which revealed that occupants were comfortable in a broader range of temperatures.^[3]

This research is applied to create Building Energy Simulation (BES) programs for residential buildings. Residential buildings in particular can vary much more in thermal comfort than public and commercial buildings. This is due to their smaller size, the variations in clothing worn, and different uses of each room. The main rooms of concern are bathrooms and bedrooms. Bathrooms need to be at a temperature comfortable for a human with or without clothing. Bedrooms are of importance because they need to accommodate different levels of clothing and also different metabolic rates of people asleep or awake.^[74] Discomfort hours is a common metric used to evaluate the thermal performance of a space.

Thermal comfort research in clothing is currently being done by the military. New air-ventilated garments are being researched to improve evaporative cooling in military settings. Some models are being created and tested based on the amount of cooling they provide.^[75]

In the last twenty years, researchers have also developed advanced thermal comfort models that divide the human body into many segments, and predict local thermal discomfort by considering heat balance.^[76][77][78] This has opened up a new arena of thermal comfort modeling that aims at heating/cooling selected body parts.

Another area of study is the hue-heat hypothesis that states that an environment with warm colors (red, orange yellow hues) will feel warmer in terms of temperature and comfort, while an environment with cold colors (blue, green hues) will feel cooler.^[79][80][81] The hue-heat hypothesis has both been investigated scientifically^[82] and ingrained in popular culture in the terms warm and cold colors ^[83]

This section relies largely or entirely on a single source. Relevant discussion may be found on the talk page. Please help improve this article by introducing citations to additional sources. Find sources: "Thermal comfort" – news · newspapers · books · scholar · JSTOR (June 2016)

Whenever the studies referenced tried to discuss the thermal conditions for different groups of occupants in one room, the studies ended up simply presenting comparisons of thermal comfort satisfaction based on the subjective studies. No study tried to reconcile the different thermal comfort requirements of different types of occupants who compulsorily must stay in one room. Therefore, it looks to be necessary to investigate the different thermal conditions required by different groups of occupants in hospitals to reconcile their different requirements in this concept. To reconcile the differences in the required thermal comfort conditions it is recommended to test the possibility of using different ranges of local radiant temperature in one room via a suitable mechanical system.

Although different researches are undertaken on thermal comfort for patients in hospitals, it is also necessary to study the effects of thermal comfort conditions on the quality and the quantity of healing for patients in hospitals. There are also original researches that show the link between thermal comfort for staff and their levels of productivity, but no studies have been produced individually in hospitals in this field. Therefore, research for coverage and methods individually for this subject is recommended. Also research in terms of cooling and heating delivery systems for patients with low levels of immune-system protection (such as HIV patients, burned patients, etc.) are recommended. There are important areas, which still need to be focused on including thermal comfort for staff and its relation with their productivity, using different heating systems to prevent hypothermia in the patient and to improve the thermal comfort for hospital staff simultaneously.

Finally, the interaction between people, systems and architectural design in hospitals is a field in which require further work needed to improve the knowledge of how to design buildings and systems to reconcile many conflicting factors for the people occupying these buildings.^[84]

Personal comfort systems (PCS) refer to devices or systems which heat or cool a building occupant personally.^[85] This concept is best appreciated in contrast to central HVAC systems which have uniform temperature settings for extensive areas. Personal comfort systems include fans and air diffusers of various kinds (e.g. desk fans, nozzles and slot diffusers, overhead fans, high-volume low-speed fans etc.) and personalized sources of radiant or conductive heat (footwarmers, legwarmers, hot water bottles etc.). PCS has the potential to satisfy individual comfort requirements much better than current HVAC systems, as interpersonal differences in thermal sensation due to age, sex, body mass, metabolic rate, clothing and thermal adaptation can amount to an equivalent temperature variation of 2–5 °C (3,6–9 °F), which is impossible for a central, uniform HVAC system to cater to.^[85] Besides, research has shown that the perceived ability to control one's thermal environment tends to widen one's range of tolerable temperatures.^[3] Traditionally, PCS devices have been used in isolation from one another. However, it has been proposed by Andersen et al. (2016) that a network of PCS devices which generate well-connected microzones of thermal comfort, and report real-time occupant information and respond to programmatic actuation requests (e.g. a party, a conference, a concert etc.) can combine with occupant-aware building applications to enable new methods of comfort maximization.^[86]

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• Thermal Comfort chapter, Fundamentals volume of the ASHRAE Handbook, ASHRAE, Inc., Atlanta, GA, 2005.
• Weiss, Hal (1998). Secrets of Warmth: For Comfort or Survival. Seattle, WA: Mountaineers Books. ISBN 978-0-89886-643-8. OCLC 40999076.
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• Humphreys, Michael (2016). Adaptive thermal comfort : foundations and analysis. Abingdon, U.K. New York, NY: Routledge. ISBN 978-0415691611.
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