Tom Kovesi MD Pediatric Respirologist Associate Professor of Pediatrics Children’s Hospital of Eastern Ontario University of Ottawa Ottawa, Canada Presentation at the HOUSING REALITIES FOR INUIT 2012 WORKSHOP, organized by Inuit Tuttarvingat of NAHO, February 16, 2012, Ottawa, Ontario.

1. RSV and The Ulu:
The Cutting Edge of Research into the
Causes of Severe Recurrent Lower
Respiratory Tract Infections in Inuit
Infants
Tom Kovesi MD
Pediatric Respirologist
Associate Professor of Pediatrics
Children’s Hospital of Eastern Ontario
University of Ottawa
Ottawa, Canada

2. Bronchiolitis
Bronchiolitis is
an infection, caused
by a virus, of the
very tiny airways
in a baby’s lungs

3. Northern Communities Have
the Highest Incidence of Severe
RSV Bronchiolitis in the World
Hospitalization Rate per 1000 infants
500
All United States
400
300
Yukon-Kuskowkwim
Delta (Alaska)
200
100
Baffin Region,
Nunavut
0
Karron, J Infect Dis 1999; Banerji, CMAJ 2001

4. Nunavut has the highest rate of
Tuberculosis infection in Canada
160
140
120
Canada (general)
100
80 Canadian
Aboriginals
60
Inuit
40
20
0
TB rates per 100,000 persons

5. What the Houses? Indoor Air?
Do they play a role?

6. What About Ventilation?
Cape Dorset Pilot Project: Kovesi, Indoor Air 2006
Multi-Community Study: Kovesi, CMAJ 2007

7. Occupancy Distribution
Median number occupants: 6, mean 5.9, range 2-12
Number of Houses 12
10
8
6
4
Cape Dorset,
20 houses of
Inuit Infants 2
(Kovesi,
0
Indoor Air
2.0 4.0 6.0 8.0 10.0 12.0
2006)
Number of People Per House

8. Environmental Tobacco Smoke
Exposure
5%
5%
90%
Smoking Reported
Likely Smoking
No Smokers
Smokers present 90% (probably 95%) of households

9. Ventilation
Ventilation within recommended Mean CO2 > 1000 ppm
Canadian standards (7.5 L/s/person)
Recommended < 1000
79.9%
66.7%
> 1000
20.1% 33.3%
Below
Recommended
• 96 Inuit children in 4 communities:
• Mean ventilation 5.6 L/s/person
• Mean CO2 1358 ppm (Kovesi, CMAJ 2007)

10. Risk of Lower Respiratory Tract
Infection
3000 12
10
2000
8
Mean CO2 (ppm)
Occupancy
6
1000
4
0 2
N= 21 13 N= 25 15
Absent Present Absent Present
Pneumonia Pneumonia
• Ventilation also known to be important risk factor for TB (Menzies, Ann Int
Med 2000)
• *too few non-smoking households to test the effect of smoking

11. Heat Recovery Ventilators
• Heat Recovery Ventilators bring fresh outside air into
furnace, transfer heat from stale air to fresh air to
maintain energy efficiency, and move stale air out of
house
• Trial of HRV’s installed in homes of Inuit children 5 years &
less in 4 communities
• HRV’s were installed in fall-winter 2006-2007:
– Clyde River
– Igloolik
– Pangnirtung
– Pond Inlet

12. Study HRV’s
• Venmar Constructo 1.0 HRV,
– (Venmar Ventilation Inc.)
• Determined that additional 25-30
L/second ventilation needed to provide
7.5 L/s/person
• Active HRV’s provided this ventilation
• Placebo units circulated air in the house,
but not increase the house’s outside
(fresh) air
• Placebo units were reprogrammed as
functional devices at end of study
(reprogram internal circuit board)

13. Conducting Research in
Nunavut
– Community Support
• Town Hall Meetings: Pilot & Multi-community
Studies; mainly assumed for HRV study
• Qikiqtani Inuit Association, Nunavut Tunngavik
Inc.
• Approval from Nunavut Research Institute,
Ministry of Health and Social Services
– Need for community research coordinators
with good organizational and computer skills
(“too few and in too much demand”
– Capacity-building: enlisted high school
students to help with collecting data

14. Heat Recovery Ventilator
Venmar HRV, Pond Inlet, Nunavut

15. HRV Study Findings - Engineering
• Installations
– 68 HRV’s installed
– 51 available for analysis
• Units (6) in Clyde River couldn’t be powered
• 3 families dismantled units
• Children in 4 families moved
• HRV’s significantly reduced indoor CO2 (33%)
– Mean CO2 1385 ppb placebo units
– Mean CO2 924 ppb active units

16. Effect of HRV’s on Reported Wheezing
• Significant reduction in risk of reported rhinitis (not
associated with cold air exposure) (p = 0.0044)

17. Challenges
• HRV’s significantly reduced relative
humidity (25.6 vs 30.9%) & tended to reduce
indoor temperature
• Occupant complaints (house colder, drier…)
• 21% active houses,
• 27% placebo houses
• Units unplugged > 50% of study period in
~20% houses (counter data, questionnaires)

18. Research Questions
• Are Heat Recovery Ventilators the answer?
– Maintenance and installation issues
– Dry air
– Small but real electricity cost
– Retrofits
• Can Heat Recovery Ventilators be engineered
better for very cold weather performance?
– Issue of drafts
• Role of overcrowding/need for new homes
versus ventilation (e.g. heat recovery
ventilators)
• Role of surface v.s. airborne transmission virus

19. Future Research (2)
• How to deal with environmental tobacco
smoke
• Human architecture of Inuit housing
• Capacity-building – research in Nunavut

20. Acknowledgements
• Program of Energy Research and
Development, NRCan
• Nassivik Centre, CIHR
• Canada Mortgage and Housing
Corporation
• Natural Resources Canada
• Qikiqtani Inuit Association
• Venmar Ventilation Inc.
• Nunavut Housing Corporation
• Health Canada
• Children’s Hospital of Eastern Ontario
Research Institute
• Department of Health and Social
Services, Government of Nunavut