Indoor Air Quality:Indoor Air Quality:Mold in the schoolsMold in the schools

By Chris Randolph, M.D.By Chris Randolph, M.D.Associate Clinical ProfessorAssociate Clinical Professor

Yale Affiliated HospitalsYale Affiliated HospitalsWaterbury, CTWaterbury, CT

Learning objectives: Learning objectives: OutlinesOutlines

To familiarize the healthcare To familiarize the healthcare provider with:provider with:

1.1. Mold associated illness in Mold associated illness in schools:schools:a.a. The Role of fungi in the The Role of fungi in the

Environment.Environment.

b.b. The health impact on schools.The health impact on schools.

c.c. The role of toxigenic fungi. The role of toxigenic fungi.

2.2. Diagnosis and remediation Diagnosis and remediation of mold in the school.of mold in the school.

DefinitionsDefinitionso FungusFungus Gr sponge: ”Any of a large division Gr sponge: ”Any of a large division

of thallophytes including molds, mildew, of thallophytes including molds, mildew, mushrooms, rusts and smuts, which are mushrooms, rusts and smuts, which are parasites on living organisms or feed upon parasites on living organisms or feed upon dead organic matter”dead organic matter”

o Reproduce by spores and lack chlorophyll, Reproduce by spores and lack chlorophyll, true roots, stems or leaves. (Webster’s New true roots, stems or leaves. (Webster’s New World Dictionary 3World Dictionary 3rdrd college edition 1994 college edition 1994 MacMillan p546-7)MacMillan p546-7)

o Mold is “downy or furry growth on the Mold is “downy or furry growth on the surface of organic matter caused by fungi surface of organic matter caused by fungi especially in presence of dampness or especially in presence of dampness or decay.” (Webster’s New World Dictionary decay.” (Webster’s New World Dictionary 1994p873)1994p873)

DefinitionsDefinitions

o Fungal Related Chemicals:Fungal Related Chemicals:o Metabolites: ToxinsMetabolites: Toxinso Components or byproducts (VOC): Ergosterol, Components or byproducts (VOC): Ergosterol,

B(1-3) glucan, VOC (volatile organic compounds)B(1-3) glucan, VOC (volatile organic compounds)o Mycotoxin: nonvolatile secondary metabolite of Mycotoxin: nonvolatile secondary metabolite of

filamentous fungi that is toxic to vertebrates filamentous fungi that is toxic to vertebrates o Produced by many fungal spores and many toxins Produced by many fungal spores and many toxins

by same species i.e. Penicillium, Alternaria, by same species i.e. Penicillium, Alternaria, Aspergillus, Fusarium as well as Stachybotrys. Aspergillus, Fusarium as well as Stachybotrys. (Webster’s 1994/ Google) (Muilenberg M Current (Webster’s 1994/ Google) (Muilenberg M Current Views All/Imm 2004)Views All/Imm 2004)

CASES: Mold Associated CASES: Mold Associated Illness in Water Damaged Illness in Water Damaged

SchoolsSchools 12 y/o w/f developed 12 y/o w/f developed

new onset “asthma” in a new onset “asthma” in a school adjacent to a school adjacent to a waterfall.waterfall.

Middle school children Middle school children developed nonspecific developed nonspecific rash, cough and/or rash, cough and/or influenza- like symptoms influenza- like symptoms in a newly constructed in a newly constructed school.school.

High School guidance High School guidance counselors developed counselors developed influenza - like symptomsinfluenza - like symptoms

Remediation with decline Remediation with decline in symptomsin symptoms

Introduction: EcologyIntroduction: EcologyMold represents a generally Mold represents a generally benign saprophyte benign saprophyte Manufacture of antimicrobials Manufacture of antimicrobials to cheeseto cheeseNow health concern stifling Now health concern stifling home sales, increasing home sales, increasing insurance, affecting schools and insurance, affecting schools and taxpayers as well with poorly taxpayers as well with poorly documented health problemsdocumented health problemsTexas insurance companies /Ed Texas insurance companies /Ed McMahon/Michael Jordan/School McMahon/Michael Jordan/School closures/State Farm and others closures/State Farm and others eliminate coverage/millions in eliminate coverage/millions in suits for attorneys (“Mold is suits for attorneys (“Mold is gold”).gold”).

ChapmanJA et al:Toxic mold:phantom riskvs science.Ann. Allergy2003:91;222-32

Belkin L.Haunted by mold.NYTimes Magazine8/12/2001p28

Ecology (Chapman 2003)Ecology (Chapman 2003) Present 559 million years ago Present 559 million years ago

or earlier in peaceful or earlier in peaceful coexistencecoexistence

Absorb water from soil, wood, Absorb water from soil, wood, decaying organic matterdecaying organic matter

Size microscopic to some of Size microscopic to some of large, multi cellular large, multi cellular organisms (6.5km2 in organisms (6.5km2 in Washington State(3 counties): Washington State(3 counties): Armillaria ostoyae fungus)Armillaria ostoyae fungus)

Include 1.5 million species / Include 1.5 million species / 100,000 identified / 10 100,000 identified / 10 primary pathogens remainder primary pathogens remainder saprobicsaprobic

Include toadstools, mildews, Include toadstools, mildews, puffballs, yeasts, smut, rusts puffballs, yeasts, smut, rusts occupy 25% of earth biomassoccupy 25% of earth biomass

Perfect and imperfect classesPerfect and imperfect classes

Chapman JA,et al.Toxic mold:phantom riskVs science.Annals Allergy,Asthma,Imm.2003;91:222-232

Ecology (Chapman 2003)Ecology (Chapman 2003) Acremonium: produces toxinAcremonium: produces toxin Alternaria: carpets, textiles, Alternaria: carpets, textiles,

window frames in building window frames in building interiorsinteriors

Aspergillus flavus water Aspergillus flavus water damaged carpets, damaged carpets,

Aspversicolor damp wood or Aspversicolor damp wood or wall paper gluewall paper glue

Cladosp. in supply ductsCladosp. in supply ducts Stachybotrys greenish black Stachybotrys greenish black

grows on cellulosegrows on cellulose Penicillium produce Penicillium produce

mycotoxins (Pexpansum, mycotoxins (Pexpansum, Pchrysogenum)Pchrysogenum)

Fusarium in humdifiers Fusarium in humdifiers Trichoderma in paper source Trichoderma in paper source

of antibiotics toxic to of antibiotics toxic to humanshumans

Common indoor CommonOutdoor:Common indoor CommonOutdoor:Cladiosporium Cladiosporium Basidiospores Basidiospores Penicillium Penicillium Cladiosporium Cladiosporium Aspergillus Aspergillus Ascospores AscosporesAlternaria Alternaria Alternaria Alternaria AureobasidiumAureobasidium Penicillium Penicillium

Aspergillus Aspergillus

These require continuous O2,These require continuous O2, water, organic material and water, organic material and suitable temperature for growth.suitable temperature for growth.

(HealthySchools Network,,Albany,NY. www.healthyschools.org

ChapmanJA et al AnnAll.2003;91:222-32

Fungi: growth conditionsFungi: growth conditions

Atmospheric conditions :Atmospheric conditions : Require 70-90% relative humidityRequire 70-90% relative humidity Grow optimally at 20-40Grow optimally at 20-40o o CC Wide variety host requirements Wide variety host requirements Some grow in hot, dry climate Some grow in hot, dry climate

(xerophilic)(xerophilic) (Terr A.The role of mold in disease. (Terr A.The role of mold in disease.

AmAcadAllAsthmaImm meeting: San AmAcadAllAsthmaImm meeting: San Francisco,California 3/04)Francisco,California 3/04)

Fungi: HabitatFungi: Habitat Outdoors: Ubiquitous: airborne globally Outdoors: Ubiquitous: airborne globally

except polar capsexcept polar caps Indoors Indoors 30-70% of outdoors30-70% of outdoors From outdoor penetration From outdoor penetration Or indoor source i.e. plant or garbageOr indoor source i.e. plant or garbage Primary host: plant especially cropsPrimary host: plant especially crops Saprophytic colonization or pathogenic Saprophytic colonization or pathogenic

(invade tissue) (Terr A. The role of mold in (invade tissue) (Terr A. The role of mold in disease (and non-disease. AAAAI 3/04) disease (and non-disease. AAAAI 3/04)

IMPACT OF FUNGI ON IMPACT OF FUNGI ON HEALTH ?HEALTH ?

AgentAgent SourceSource PathwayPathway Adequate doseAdequate dose OutcomeOutcome Null hypothesis: Damp, cold and Null hypothesis: Damp, cold and

moldy environments are not moldy environments are not associated with poorer health.associated with poorer health.

FungiFungi

o Areas of medical concernAreas of medical concerno AllergensAllergenso InfectivityInfectivityo ToxinsToxins

Terr A.The role of mold in disease and nondisease.AmAcadAllAsthmaImm. Meeting. SanFrancisco ,California ,3/04.

Toxic mold:Toxic mold:phantom risk vs sciencephantom risk vs science

Mold associated disease :need for Mold associated disease :need for controls and standards for exposurecontrols and standards for exposure

Length exposure and individual Length exposure and individual sensitivitysensitivity

4 categories:4 categories: Anecdotal evidenceAnecdotal evidence Case studiesCase studies Epidemiologic studiesEpidemiologic studies Experimental evidenceExperimental evidence Consequences of low level mold Consequences of low level mold

unknownunknown Synergism with indoor aerosolsSynergism with indoor aerosols Mold panic replace with scienceMold panic replace with science

Chapman et al Annals All2003;91:222-232

Burge,Annals 2003;91:217-219Burge,Annals 2003;91:217-219

Dales RE,CakmakS,BurnettRT,et al.Am J RespCrit Care Med 2000;162(6):2087-90.

Indoor Air Quality in Indoor Air Quality in SchoolsSchools

(Dishop,2002)(Dishop,2002) Airtight schools :1960-1970”modular format “was walled in w/o Airtight schools :1960-1970”modular format “was walled in w/o

installation of adequate air circulation. (Morris,AB. Does design make a installation of adequate air circulation. (Morris,AB. Does design make a difference? Conf AIAComm Arch.Educ.AIA 1997)difference? Conf AIAComm Arch.Educ.AIA 1997)

Poor maintenance leads to water injury medium for mold and fungal Poor maintenance leads to water injury medium for mold and fungal allergenallergen

Sources indoor air quality: covered air supply, return ventilation, Sources indoor air quality: covered air supply, return ventilation, improperly maintained radiator and air filters, ins. sealed cleaning and improperly maintained radiator and air filters, ins. sealed cleaning and maintenance chemicals. Wooden construction >concrete (Meklin T.AIHA maintenance chemicals. Wooden construction >concrete (Meklin T.AIHA Journal2003;64:108-116) Journal2003;64:108-116)

Other sources classroom pets, second hand smoke, Other sources classroom pets, second hand smoke, labs, copier, furnace room vents and ventilationlabs, copier, furnace room vents and ventilation system, water and moisture injury, eating facilities,system, water and moisture injury, eating facilities, upholstered furniture.upholstered furniture. Children most vulnerable particularly with allergic Children most vulnerable particularly with allergic rhinitis and asthma per Institute of medicine rhinitis and asthma per Institute of medicine because they are low to ground have less body because they are low to ground have less body mass and breath more rapidly.mass and breath more rapidly. AAP Statement: Damp mold ridden environment AAP Statement: Damp mold ridden environment is unhealthy particularly for individuals withis unhealthy particularly for individuals with respiratory conditions.respiratory conditions.Dishop ML. Maintaining Environmental Cleanliness in School. Suppl JSchNursing 2002 (Oct):23-26

DishopML.Maintaining environmental cleanliness in school.SupplJSch NursOctober 2002.

Total airborne and Total airborne and viable fungi in schoolsviable fungi in schools

Total airborne (Daisey et al Indoor Air 2003) and Total airborne (Daisey et al Indoor Air 2003) and surface fungi in 13 classrooms in 6 Florida schools in surface fungi in 13 classrooms in 6 Florida schools in 10 papers.10 papers.

Health complaints: stuffy sinuses, sore throat, Health complaints: stuffy sinuses, sore throat, respiratory illness, lethargy, itchy eyes and runny respiratory illness, lethargy, itchy eyes and runny nose. Concentration >1000CFU/m3 in one complaint nose. Concentration >1000CFU/m3 in one complaint and non-complaint all others <700CFU/m3 (Bates and non-complaint all others <700CFU/m3 (Bates and Maffy,1996)and Maffy,1996)

Average and maximum total viable molds measured Average and maximum total viable molds measured in 96 classrooms in 38 Swedish schools: 500CFU/M3 in 96 classrooms in 38 Swedish schools: 500CFU/M3 and 4,500CFU/m3 (Smedje et al, 1996, 1997)and 4,500CFU/m3 (Smedje et al, 1996, 1997)

Carpeted 1900CFU/g dust vs. bare floors Carpeted 1900CFU/g dust vs. bare floors 950CFU/g(p=.0.002)950CFU/g(p=.0.002)

Most prevalent genera: Penicillium, Fusarium, Most prevalent genera: Penicillium, Fusarium, Alternaria and Cladosporium (Gravesen et al,1986)Alternaria and Cladosporium (Gravesen et al,1986)

TerrA.JAll Clin Imm2004;113:221

Reference History Phy. Exam Affected Bldg.

Spec. mold(s) implicated

Croft et al 1985 16

5 persons: cold, flu, sore throats, diarrhea, headaches, fatigue, dermatitis, alopecia, malaise

Repeatedly Neg.

Home Stachybotrys species

Brunekreef et al 1989 22

6273 US children (respiratory questionnaire) no control subjects

Not done Homes Total molds, spores

Platt et al 1989 25

1169 UK children in 597 households: excess bad nerves, aching joints, nausea and vomiting, backache, blocked nose, fainting spells, constipation, breathlessness

Not done Homes measured Dampness or mold

Total molds, spores

Strachan et al 1990 24

Children with asthma wheezed more in homes with higher mold counts

Yes, Spirometry

Homes mold quantitation

Total molds, spores

Li & Hsu 1996 23

1370 Children : questionnaire for self-report of dampness, mold & respiratory symptoms

Not done Homes Total molds, spores

Cooley et al 1998 20

622 Adult workers at 48 schools with indoor air quality complaints: no control subjects

Not done Schools Penicillium species, strachybotrys species

Johanning et al, 1999 21

Descriptive study: 22 children and 125 adults with multiple symptoms

Done, not reported

Homes (no data on fungal exposure

strachybotrys species

Santilli & Rockwell 2003 27

Rhinitis questionnaire: 85 students & teachers

Not done 2 schools Total molds, spores

Cooley J.Occupational Environ Med 1998:55:579-584

Mold in Schools: StudiesMold in Schools: Studies Allergy in form of RAST to molds and (+) PST particularly Allergy in form of RAST to molds and (+) PST particularly

Aspergillus associated with IgG antibodies to molds found in mold Aspergillus associated with IgG antibodies to molds found in mold damaged building. No association was found IgG to mold and damaged building. No association was found IgG to mold and exposure in school.(TaskinenTMetal.Allergy:2002.57(1)9-16)exposure in school.(TaskinenTMetal.Allergy:2002.57(1)9-16)

Sinusitis in teachers associated with elevated mold specific IgG Sinusitis in teachers associated with elevated mold specific IgG to multiple fungi including Aspergillus and Stachybotrys with to multiple fungi including Aspergillus and Stachybotrys with decrease in IgG on 2 year followup with sinusitis/bronchitis.decrease in IgG on 2 year followup with sinusitis/bronchitis.(PatovirtaetalIJOMEH2003;16(3)(PatovirtaetalIJOMEH2003;16(3)

Association between elevated IgG to Penicillium notatum and Association between elevated IgG to Penicillium notatum and E.amstelodami and moisture damage in school.E.amstelodami and moisture damage in school.(HyvarinenA .ArchEnHlth2003;58(5):275-83)(HyvarinenA .ArchEnHlth2003;58(5):275-83)

Mold in floor dust had no positive association with building Mold in floor dust had no positive association with building related symptom.but 5/8 symptoms secondary to related symptom.but 5/8 symptoms secondary to asthma ,hayfever,recent airway infection or psychosocial factors.asthma ,hayfever,recent airway infection or psychosocial factors.(Meyers:IndoorAir2004;14:65-72)(Meyers:IndoorAir2004;14:65-72)

Childrens’ perception of symptoms increased after publicized that Childrens’ perception of symptoms increased after publicized that exposure to mold in schools related to cough,wheezing and joint exposure to mold in schools related to cough,wheezing and joint pains.(Handal Get al Indoor Air 2004;14:87-91 )pains.(Handal Get al Indoor Air 2004;14:87-91 )

Mold in schoolsMold in schools 33% U.S. public schools 33% U.S. public schools

need extensive need extensive repair(6/96GAO)repair(6/96GAO)

Two Connecticut public Two Connecticut public schools (Fairfield County) schools (Fairfield County) tested using multiple air tested using multiple air quality testing methods quality testing methods with standard for healthy with standard for healthy indoor environment for total indoor environment for total mold spore counts mold spore counts 1,000spores/m31,000spores/m3

In both schools counts were In both schools counts were elevated (1elevated (1stst : 6000-50,000 : 6000-50,000 sp/m3, 2sp/m3, 2ndnd 2-9000 sp/m3) 2-9000 sp/m3) with associated allergic with associated allergic symptoms. Both were symptoms. Both were remediated. The first school remediated. The first school was demolished and rebuilt. was demolished and rebuilt.

Santilli et al :Ann Allergy Asthma Imm.2003;90:203-208

Santilli J et al. Fungal contamination of elementary schools: a new environmental hazard.Ann Allergy Asthma Imm2003;90:203-8.

Santilli J etal.Fungal contamination of elementary schools:a new environmental hazard.Ann Allergy Asthma Immunol 2003;90:203-8

Fungi: Environmental Fungi: Environmental assessmentassessment

Air sampling: examples Standard > 1000sp/ Air sampling: examples Standard > 1000sp/ m3, 100 cfu/m3, 75% (I-O).m3, 100 cfu/m3, 75% (I-O).

1. Viable: culture plates colony counts1. Viable: culture plates colony counts2. Nonviable: spores (spores/m3)2. Nonviable: spores (spores/m3)

3. Surface sample (swipe) Qualitative 3. Surface sample (swipe) Qualitative only only

Multiple samples: agitation/indoor /outdoorMultiple samples: agitation/indoor /outdoor Good labs certified Good labs certified

www.aiha.orgwww.aiha.org,, www.aaaai.orgwww.aaaai.org,,.. www.paaa.orgwww.paaa.org

Terr A. The role of mold in disease and non disease, Amer, Acad All Asthma ImmMeeting San Francisco, California 3/04

Carpet Samplings Colony Forming Units/Gm

Room 117 108,500,000

Room 118 20,120,000

Room 221 1,970,000

Wall Cavity Samplings Mold Spores/m3 Room 107 156,666

Room 117 106,667

Room 121 120,000

Table 1 Turner Environmental’s Testing of Mckinley Elementary School Revealed Severe Mold Contamination of the Wall Cavities and Rugs

Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:203-208

Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:203-208

1297

908 872

567 531425

412 264 260

0200

400

600

8001000

1200

1400

Col

ony

For

min

g U

nits

/m3

FacultyRoom

Room 220 Caferteria Room 221 Room 218 Room 210 Room 222 MediaRoom

Outdoors

Room

Figure 4 Results of ASHA testing indoor air quality at Mckinley Elementary School

53,000

6,5001,900

0

10,000

20,000

30,000

40,000

50,000

60,000

Tot

al M

old

Spor

es

Cou

nts/

m3

Room 107 Gym Outdoors

Room

Fig 5 Results of Turner Environmental testing indoor air quality at Mckinley Elementary School

Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:203-208

Some less common symptoms:Some less common symptoms: fever, vomiting, nausea, nosebleeds, dizziness, memory loss, fever, vomiting, nausea, nosebleeds, dizziness, memory loss,

diarrhea and changes in behavior Mycotoxin related symptomsdiarrhea and changes in behavior Mycotoxin related symptoms

vomiting

Fatigue

Headaches

Flu symptoms

New or aggravated

Asthma

Irritated eyes

Congestion

Coughing

Runny Nose

Symptoms

MuilenbergML.Toxigenic fungi.Current Views in All Imm V;XXXII I/04. MedCollGeo.

Amr S et al.Environmental Allergens and Asthma in Urban Elementary Schools. Ann Allergy Asthma Immunol 2003;90:34-40

Mold in schoolsMold in schools Skin prick test findings from moisture and mold damaged Skin prick test findings from moisture and mold damaged

schools: Mold allergy in a 3 year follow up disappeared in 2 schools: Mold allergy in a 3 year follow up disappeared in 2 children and developed in 5.children and developed in 5.

5/6 of children with reactions >/= 3mm to molds had (+) 5/6 of children with reactions >/= 3mm to molds had (+) response to other allergens response to other allergens

5 children had clinical atopy/2 asthma5 children had clinical atopy/2 asthma All six children had been exposed to moisture and All six children had been exposed to moisture and

dampness in the school buildings dampness in the school buildings Most reactions to molds in child >14y with multiple SPT Most reactions to molds in child >14y with multiple SPT

reactions to common allergens but no association with reactions to common allergens but no association with asthma asthma

Immonen Jet al Pediatric Allergy and Imm.:2001;12(2):87-94

Toxigenic FungiToxigenic FungiM.L. MuilenbergM.L. Muilenberg

Livestock exposures to mycotoxinsLivestock exposures to mycotoxins Human food and mycotoxinsHuman food and mycotoxins The toxigenic fungi and their mycotoxinsThe toxigenic fungi and their mycotoxins

Alternaria, Aspergillus, Fusarium, Penicillium, Alternaria, Aspergillus, Fusarium, Penicillium, StachybotrysStachybotrys

Respiratory exposures to mycotoxinsRespiratory exposures to mycotoxins Sampling and exposureSampling and exposure RecommendationsRecommendations SummarySummary

Muilenberg M.Toxigenicfungi .Current Views in Allergy Immunology.2004;VolumeXXXII.Program4(January)Medical College of Georgia.

Mycotoxins (Etzel RA,JAMA 2002)Mycotoxins (Etzel RA,JAMA 2002)Aflatoxins Aspergillus Flavus Corn GI/ Neuro

Clavine alkaloids Claviceps Fusiformis Millet GI/ Drow.

Ergometrine C. Purpurea (St. A Fire)

Barley GI/ N/ Gang

Fumonisms Fusarium (horse, swine)

Corn N/P/Death

Cyclopiazonic Aspergillus Millet GI/ Giddy

Ochratoxin Penicillum / Asp Grains Renal

T 2 Toxin Fusarium (cattle) Corn Abortion

Trichothecenes Fusarium / Asp Wheat GI

Tremorgens Asp/ Pen/ Muc/ Rh/ Cep

Grass/ Alf

GI/ N

Slaframine Rhizo (horse, cattle, sheep)

Gr/ Wh GI/ N

Etzel RA.Mycotoxins.JnlAmer.Med Ass.2002;287(4):425-7.

Human Human StachybotryotoxicosisStachybotryotoxicosis

By ingestion: 1930’s in Siberia horses fed moldy By ingestion: 1930’s in Siberia horses fed moldy grain developed agranulocytosis, GI hemorrhage and grain developed agranulocytosis, GI hemorrhage and ulceration similar reports in sheep, other animals ulceration similar reports in sheep, other animals and farmers.and farmers.

1942 USSR Academy of Sciences (VG Drobotko)1942 USSR Academy of Sciences (VG Drobotko) By inhalation never proven in humans would require By inhalation never proven in humans would require

massive doses seen in agricultural or remediation massive doses seen in agricultural or remediation settings (x10 to 6settings (x10 to 6th th powerpower or more spores/mm3) or more spores/mm3)

2.1 x 106 spores / m3 for infant 15.3 x 106spores 2.1 x 106 spores / m3 for infant 15.3 x 106spores /m3 for an adult./m3 for an adult.

Acute interstitial pulmonary hemosiderosis (AIPH)Acute interstitial pulmonary hemosiderosis (AIPH)

(Terr A. Mold in disease and non-disease AAAAI3/2004)(Muilenberg M (Terr A. Mold in disease and non-disease AAAAI3/2004)(Muilenberg M Current Views Allergy Immunology 2004; Volume XXXII. Prog4. Med. Current Views Allergy Immunology 2004; Volume XXXII. Prog4. Med. CollGeoCollGeo..

Summary continuedSummary continued CDC investigation 1999CDC investigation 1999

Conclusion:Conclusion: A possible association between acute pulmonary A possible association between acute pulmonary

hemorrhage…and (mold) exposure …was not proven hemorrhage…and (mold) exposure …was not proven (CDC.Report of working group on pulm. hemorrhage and (CDC.Report of working group on pulm. hemorrhage and hemosiderosis, CDC and Prevention,1999)hemosiderosis, CDC and Prevention,1999)

Human diseases from mold:Human diseases from mold: Specific molds produce infectious or allergic diseaseSpecific molds produce infectious or allergic disease

Toxic conditions from inhalation of mold spores is Toxic conditions from inhalation of mold spores is unproven. (Terr AThe role of mold in disease and unproven. (Terr AThe role of mold in disease and non-disease. AAAAI 3/04)non-disease. AAAAI 3/04)

Current scientific evidence does not support…that Current scientific evidence does not support…that human health has been adversely affected by human health has been adversely affected by inhaled mycotoxins in home, school or office inhaled mycotoxins in home, school or office environments. ACOEM JOEM 2003;45(5):470-78environments. ACOEM JOEM 2003;45(5):470-78

DIAGNOSIS DIAGNOSIS &&

REMEDIATIONREMEDIATION NHLBI:NHLBI: Goals for Healthy School Goals for Healthy School

EnvironmentEnvironment Keep temperature and Keep temperature and

humidity appropriatehumidity appropriate Maintain HVAC systemsMaintain HVAC systems Dry up damp and wet areas Dry up damp and wet areas

within 1-2 dayswithin 1-2 days Minimize exposure to Minimize exposure to

triggers: smoke, chemical triggers: smoke, chemical vapors, chalk dust, mold, vapors, chalk dust, mold, fumes and animals.fumes and animals.

Approach for PatientApproach for Patiento Log of walk through Log of walk through

school : check for mold or school : check for mold or water damage, stagnant water damage, stagnant water, inadequate water, inadequate ventilation, air intake grillsventilation, air intake grills

o Check ceilings, tiles, walls Check ceilings, tiles, walls looking for water stains looking for water stains including inside closets, including inside closets, boxes and behind furniture boxes and behind furniture

o Damp musty smell or Damp musty smell or visible colored deposits visible colored deposits green, brown, yellow or green, brown, yellow or black should be taken care black should be taken care of immediately to prevent of immediately to prevent spreading spreading

o Tell your doctorTell your doctor(Healthy Schools Network, Inc:Albany,NY www.healthyschools.org)

Evaluation of Building Evaluation of Building related illness by specialistrelated illness by specialist

Comprehensive history: nature of symptoms, home, work Comprehensive history: nature of symptoms, home, work environment, medical and family history.environment, medical and family history.

Physical exam: signs of systemic fungal, Tb and Physical exam: signs of systemic fungal, Tb and pneumocystis pneumoniapneumocystis pneumonia

Atopy: skin and serologic testing and PFT pre and post Atopy: skin and serologic testing and PFT pre and post bronchodilatorbronchodilator

Chest x-ray /CT of chestChest x-ray /CT of chest Supportive testing serologic Ig to fungi, for humoral and cell Supportive testing serologic Ig to fungi, for humoral and cell

med immunity and pneumonitismed immunity and pneumonitis Environmental assess: walk through and sample Environmental assess: walk through and sample

measurement of vacuumed dust sample and water damaged measurement of vacuumed dust sample and water damaged areas by prof. hygienistareas by prof. hygienist

Measurement of total symptom scores inside and outsideMeasurement of total symptom scores inside and outside Pre-bronchodilator and post-bronchodilator measurement of Pre-bronchodilator and post-bronchodilator measurement of

spirometry inside and outside home or workplace every 2-4 spirometry inside and outside home or workplace every 2-4 hrs while awake and correlate with environmental exposure hrs while awake and correlate with environmental exposure measurement.measurement.

Tools for schools EPA (Environmental Protection Agency)Tools for schools EPA (Environmental Protection Agency) OSHA (Occupational Safety and Health Administration)OSHA (Occupational Safety and Health Administration)

Chapman et al Annals Allergy,Asthma,Immunol2003;91:222-232

Method Advantage Disadvantage Implications

Visual id air sample Rapid for airborne exposure sensitive

No species,laborious

Inhaled species associate disease

Culture Identify species assay for mycotoxins

Laborious must grow on media not sensitive

Inhaled spores cause disease

Questionaire Inexpensive Not specific or validated

Allergen Immunoassay

Very sensitive specific for genera

Monoclonal too specific

Measures allergic potential

Mycotoxins Toxic potental of exposure

Assay difficult to reproduce: EIA Chromotography

Organ toxicity

Ergosterol Fungal Mass Not useful for taxa None

EPSs To identify genera None

B(1-3) glucan Fungal Mass Non-fungal sources affect

Inflammation

VOCs(Volatile organic compounds)PCR need standards

Specific for taxa Non-fungal sources affect

Irritant

TABLE : METHODS FOR IDENTIFICATION OF INDOOR FUNGAL EXPOSURE

BUSH R,PORTNOY J.The role and abatement of fungal allergens in allergic disease.JALLERGY CLIN IMMUNOL2001;107:S430-440

Results ReportResults Report Scope of workScope of work Site physical descriptionSite physical description Review of mechanical systems: HVAC, etcReview of mechanical systems: HVAC, etc Sample location and circumstancesSample location and circumstances Summary analytic results and Summary analytic results and

recommendations including walk-throughrecommendations including walk-through Analytic reports: IAQ measurements with Analytic reports: IAQ measurements with

spore counts by genus indoor and outdoor spore counts by genus indoor and outdoor ratio, rooms sampled, bulk and surface ratio, rooms sampled, bulk and surface samples , vacuum dust samples in CFU/gm or samples , vacuum dust samples in CFU/gm or m2,instruments used, lab reports (Portnoy J m2,instruments used, lab reports (Portnoy J Allergy Clin Imm.2004;113(2):190-198Allergy Clin Imm.2004;113(2):190-198

Assessment and Assessment and remediation of indoor fungiremediation of indoor fungi

Prompt remediation of contaminated material and infrastructure repair.Prompt remediation of contaminated material and infrastructure repair.

Prevent contamination through proper building, heating, ventilation, air Prevent contamination through proper building, heating, ventilation, air conditioning (HVAC) maintenance and repair of water damage. (Tools)conditioning (HVAC) maintenance and repair of water damage. (Tools)

More research needed to link health outcomes and mycotoxins.More research needed to link health outcomes and mycotoxins.

Env assessment: visual inspection HVAC, ceilings, gypsum wallboard, Env assessment: visual inspection HVAC, ceilings, gypsum wallboard, paper and cellulose containing surfaces.paper and cellulose containing surfaces.

Indoor and outdoor comparisons (no standard or human dose Indoor and outdoor comparisons (no standard or human dose response) range upward from 100CFU/m3.School closures and response) range upward from 100CFU/m3.School closures and rebuilding.rebuilding.

Remediation of water damage or condensation immediately (RH<60%) Remediation of water damage or condensation immediately (RH<60%) control mold by 4 different levels 10 sq ft to 100sq ft and HVAC (NYC control mold by 4 different levels 10 sq ft to 100sq ft and HVAC (NYC Dept Hlth) (USEPA, OSHA, Amer Conf Gov Ind. Hygenists) see WWWDept Hlth) (USEPA, OSHA, Amer Conf Gov Ind. Hygenists) see WWW

Concern little science to support public reaction (“black box”).Concern little science to support public reaction (“black box”).

Chapman et al .Toxic mold:phantom risk vs science.Annals Allergy Asthma ,Immunol 91:222-232

Checklist for mold Checklist for mold remediationremediation

Communicate with building Communicate with building occupants at all times with occupants at all times with designated persondesignated person

Plan remediation: trained Plan remediation: trained remediation personnel, proper remediation personnel, proper containment equipment and containment equipment and personal protective equipment, personal protective equipment, cleanup mold items and drying non-cleanup mold items and drying non-moldy materials within 48 hours.moldy materials within 48 hours.

Remediation moisture and mold Remediation moisture and mold problems:problems:

Fix moisture problems including Fix moisture problems including maintenance and/or repairmaintenance and/or repair

Eliminate porous material infested Eliminate porous material infested with mold that can’t be cleaned.with mold that can’t be cleaned.

EPA.Mold remediation in schools and commercial buildings .EPA402-K-01-001.3/01.

ConclusionsConclusions Rigorous prospective studies linking exposure Rigorous prospective studies linking exposure

to mold in water damaged school environments to mold in water damaged school environments and subsequent human disease need to be and subsequent human disease need to be done.done.

In the interim if after careful inspection more In the interim if after careful inspection more extensive water damage (>10 sq ft) is extensive water damage (>10 sq ft) is suggested especially with symptomatic suggested especially with symptomatic personnel, then professional investigation by personnel, then professional investigation by OSHA and industrial hygienist with micro and OSHA and industrial hygienist with micro and bulk sampling as well as appropriate air bulk sampling as well as appropriate air sampling indoor and outdoor is recommended.sampling indoor and outdoor is recommended.

Remediation to correct existing and prevent Remediation to correct existing and prevent further water damage should then be done by further water damage should then be done by professionals.professionals.

Resource list: EPAResource list: EPA IAQ (Indoor air quality) in IAQ (Indoor air quality) in

schools schools www.epa.gov/iaq/schools/index.www.epa.gov/iaq/schools/index.htmlhtml

Mold remediation in schoolsMold remediation in schools

www.epa.gov/iaq/pubs/molds.htwww.epa.gov/iaq/pubs/molds.htmlml

Indoor air quality(IAQ)home Indoor air quality(IAQ)home pagepage

www.epa.gov/iaqwww.epa.gov/iaq EPA IAQ ClearinghouseEPA IAQ Clearinghouse

iaqinfo@aol.comiaqinfo@aol.com

Mold Remediation LabsMold Remediation Labs

Aerobiology Instruction & Aerobiology Instruction & ResearchResearch465 Washington St., #1465 Washington St., #1Brookline, MA  02446Brookline, MA  02446

Aerobiology Lab Assoc., Inc.Aerobiology Lab Assoc., Inc.11800 Sunrise Valley Dr, Suite 11800 Sunrise Valley Dr, Suite 12501250Reston, VA  20191Reston, VA  20191

Environmental Microbiology LabEnvironmental Microbiology Lab10636 Scripps Summit Ct., Ste. 10636 Scripps Summit Ct., Ste. 103103San Diego, CA  92131San Diego, CA  92131

P&K/Aerotech Microbiology P&K/Aerotech Microbiology Services, Inc.Services, Inc.1936 Olney Ave.1936 Olney Ave.Cherry Hill, NJ  08003Cherry Hill, NJ  08003(RT-PCR; culture, spore ID)(RT-PCR; culture, spore ID)

Environmental Testing and Environmental Testing and Technology, Inc.Technology, Inc.4176 Mt. Hukee Ave.4176 Mt. Hukee Ave.San Diego, CA  92117San Diego, CA  92117

Air Quality Sciences, Inc.Air Quality Sciences, Inc.Atlanta, GAAtlanta, GA(770)933-0638(770)933-0638

EMSL Analytical, Inc. EMSL Analytical, Inc. N. Miami Beach, FL N. Miami Beach, FL (800)220-3675(800)220-3675

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49.49. EPA .Mold remediation in schools and commercial EPA .Mold remediation in schools and commercial buildings.EPA 402-K-001 March 2001USEPAbuildings.EPA 402-K-001 March 2001USEPA