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11 Damp Indoor Space and Your Patient : What’s Mold Got To Do With It? Carl Baum, MD, FAAP, FACMT Associate Professor of Pediatrics Yale University School.

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Presentation on theme: "11 Damp Indoor Space and Your Patient : What’s Mold Got To Do With It? Carl Baum, MD, FAAP, FACMT Associate Professor of Pediatrics Yale University School."— Presentation transcript:

1 11 Damp Indoor Space and Your Patient : What’s Mold Got To Do With It? Carl Baum, MD, FAAP, FACMT Associate Professor of Pediatrics Yale University School of Medicine Director, Center for Children’s Environmental Toxicology Yale-New Haven Children’s Hospital Marian L Heyman, MT (ASCP), MPH Epidemiologist/Industrial Hygienist Coordinator, Indoor Environmental Quality Prg Environmental Epidemiology & Occupational Health Program Connecticut Dept. of Public Health

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4 4 Case 15-year-old girl presents to your office15-year-old girl presents to your office Complains of acutely increased WOBComplains of acutely increased WOB History:History: –“I’m allergic to mold” –Petitioned last year to change schools –Re-entered old school for a rehearsal –Became acutely short of breath

5 5 Case 15-year-old girl15-year-old girl Increased WOBIncreased WOB Physical Exam:Physical Exam: –Anxious, hyperventilating –T = 37 C P = 90 RR = 45 BP = 130/70 –Room air oxygen saturation = 100% –Chest: CTA without wheeze; good aeration

6 6 Case 15-year-old girl15-year-old girl Increased WOBIncreased WOB Assessment?Assessment? Plan?Plan?

7 77 Mycology Basics Fungi = yeasts and mold Yeasts UnicellularUnicellular Round, globoseRound, globose Most reproduce by buddingMost reproduce by budding Mold Multicellular, filamentous Multicellular, filamentous Filaments - hyphae Filaments - hyphae “mat” of hyphae = mycelium “mat” of hyphae = mycelium Reproduce from fruiting body via conidia (spores) which can become airborne Reproduce from fruiting body via conidia (spores) which can become airborne

8 88 Fast Facts About Fungi Lack chlorophyllLack chlorophyll Depend on external food sourcesDepend on external food sources Must have water to grow!Must have water to grow! Thousands of fungal speciesThousands of fungal species Ubiquitous in nearly all environmentsUbiquitous in nearly all environments “But before you move to Antarctica, remember that mold spores also grow indoors, making it a year-round problem.” Asthma & Allergy Foundation of America

9 99 Fast Facts About Fungi Fungal cell walls containFungal cell walls contain 1-3-ß-d-Glucan, which can cause inflammation. 1-3-ß-d-Glucan, which can cause inflammation. Spores & mycelium contain allergens; most have not been chemically characterizedSpores & mycelium contain allergens; most have not been chemically characterized Many of the known fungal allergens are proteins found in fairly high concentrations in the spores.Many of the known fungal allergens are proteins found in fairly high concentrations in the spores.

10 10 Fast Facts About Fungi Fungal spores size range: 1 to 50 ųm.Fungal spores size range: 1 to 50 ųm. Humidity can affect sizeHumidity can affect size Spores < 10 ųm can be deposited in alveoli; smaller can be swallowedSpores < 10 ųm can be deposited in alveoli; smaller can be swallowed Lower airway deposition for 5 ųm particles is six times higher in newborns than in adults (Phalen and Oldham 2001)Lower airway deposition for 5 ųm particles is six times higher in newborns than in adults (Phalen and Oldham 2001) The spores in some species contain low molecular weight chemicals that are cytotoxic [mycotoxins]The spores in some species contain low molecular weight chemicals that are cytotoxic [mycotoxins] Alternaria spores Cladosporium spores Penicillium sp.Stachybotris spores

11 11 Medically Important Fungi Most belong to phylum Deuteromycota, or Fungi ImperfectiMost belong to phylum Deuteromycota, or Fungi Imperfecti Aspergillus fumigatus Disease Ranges: Superficial mycoses with no pathological changes to systemic mycoses- invasive, lethal Lung Tissue: Fungal Pneumonia- Aspergillus fumigatus Note septate hyphae, dichotomous branching

12 12 Indoor Environmental Fungi Opportunistic FungiOpportunistic Fungi –Almost exclusively affect debilitated patient –Allergy in pts w/ underlying respiratory conditions i.e., asthma or cystic fibrosis –Opportunistic infections in immunocompromised pts Enter buildings on our clothes, shoes, pets, windows, doors, mechanical ventilation systemsEnter buildings on our clothes, shoes, pets, windows, doors, mechanical ventilation systems

13 13 Mold Is In Every Home In The USA Just because mold is found in a building, it doesn’t mean everyone will be exposed or become symptomatic. In order to be exposed, people must either: Inhale airborne spores or fungal byproductsInhale airborne spores or fungal byproducts Skin contact (dermal exposure)Skin contact (dermal exposure) Eat it (ingestion)Eat it (ingestion)

14 14 What are the Reported Health Effects? AllergicAllergic InfectiousInfectious ToxicToxic

15 15 Allergic 10% of population has antibodies to fungal antigens10% of population has antibodies to fungal antigens 5% expected to show clinical illness5% expected to show clinical illness –allergic asthma –allergic rhinitis (“hay fever”) Hypersensitivity pneumonitisHypersensitivity pneumonitis –more serious but rare Outdoor molds more abundantOutdoor molds more abundant

16 16 Infectious Benign tineaBenign tinea –…pedis, cruris, corporus, onychomycosis PathogenicPathogenic –Blastomyces –Coccidioides –Cryptococcus –Histoplasma

17 17 Toxic Secondary metabolites (mycotoxins)Secondary metabolites (mycotoxins) –not required for survival of fungus Clinical useClinical use –PCN, CSA InhalationInhalation –blamed for numerous non-specific symptoms

18 18 MMWR January 17, 1997 / 46(02);33-35 Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants -- Cleveland, Ohio, In November 1994, private physicians and public health officials in Cleveland, Ohio, and CDC reported a cluster of eight cases of acute pulmonary hemorrhage/ hemosiderosis that had occurred during January 1993-November 1994 among infants in one area of the city (1). Two additional cases were identified in December All 10 infants lived within seven contiguous postal tracts in eastern metropolitan Cleveland. Pulmonary hemorrhages recurred in five of the infants after they returned to their homes shortly after hospital discharge; one infant died as a result of pulmonary hemorrhage.

19 19 Acute Idiopathic Pulmonary Hemorrhage Cluster of 10 infants in ClevelandCluster of 10 infants in Cleveland 1 or more hemorrhagic episodes1 or more hemorrhagic episodes 1 death1 death CDC case-control study identified 2 associationsCDC case-control study identified 2 associations

20 20 Case-control Study Major associationsMajor associations –Major water damage in previous 6 months –Increased levels of Stachybotrys chartarum HypothesisHypothesis –AIPH may be caused by mycotoxins “further research is needed to determine causal[ity]”“further research is needed to determine causal[ity]”

21 21 Case-control Study Findings cited inFindings cited in –Environmental health guidelines –Congressional testimony –Popular media

22 22 August 12, 2001

23 23 “Haunted by Mold” Melinda BallardMelinda Ballard Dripping Springs, TXDripping Springs, TX “…she pulls out two portable respirator masks. “These won’t screen out all the mycotoxins,” she warns as she tosses one to me. “That’s the dangerous stuff, so we’ll only stay a few minutes.”“…she pulls out two portable respirator masks. “These won’t screen out all the mycotoxins,” she warns as she tosses one to me. “That’s the dangerous stuff, so we’ll only stay a few minutes.”

24 24 “Haunted by Mold” 4-year-old son became ill4-year-old son became ill –“coughing up blood” –“equilibrium…completely shot” –“very bad stomach problems” vomiting, diarrheavomiting, diarrhea –“…it just spanned the whole globe in terms of symptoms.”

25 25 Arizona Republic, 1/11/02

26 26 “Mold Kids” 12 teens from Amity High and Jr High, CT12 teens from Amity High and Jr High, CT Many homebound or transferred to other schools because of “mold-related symptoms”Many homebound or transferred to other schools because of “mold-related symptoms” –“respiratory distress” –“…still suffers from a sinus infection as a result of her time at [Amity] Junior High.” Orange Bulletin, 4/14/04

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29 29 Review of AIPH Investigation Reported OR of 9.8 for change of 10 CFU/m 3Reported OR of 9.8 for change of 10 CFU/m 3 –Statistically unstable and potentially inflated –OR =1.5? SamplingSampling –Not blinded (2x in case homes) and aggressive Water-damage classificationWater-damage classification –Little difference in airborne S. chartarum levels –Unrecognized correlate of water damage?

30 30 Review of AIPH Investigation Evidence not of sufficient quality to support an association between AIPH and S. chartarumEvidence not of sufficient quality to support an association between AIPH and S. chartarum Clusters of AIPH have not been reported in other flood-prone areas where S. chartarum and other toxigenic fungi might be favoredClusters of AIPH have not been reported in other flood-prone areas where S. chartarum and other toxigenic fungi might be favored

31 31 Evidence-based Medicine ACOEM (2002)ACOEM (2002) IOM (2004)IOM (2004) WHO (2009)WHO (2009)

32 32 ACOEM 2002 evidence-based statement2002 evidence-based statement –Current scientific evidence does not support causal relationship between inhaled mycotoxins and adverse health effects

33 33 Evidence-based Medicine CDC requestCDC request –Institute of Medicine (IOM) Committee on Damp Indoor Spaces and HealthCommittee on Damp Indoor Spaces and Health

34 34 IOM 2004 Report2004 Report –341 pages

35 35 Damp Indoor Spaces: Categories of Evidence Sufficient evidence of a causal relationshipSufficient evidence of a causal relationship Sufficient evidence of an associationSufficient evidence of an association Limited or suggestive evidence of an associationLimited or suggestive evidence of an association Inadequate or insufficient evidence to determine whether an association existsInadequate or insufficient evidence to determine whether an association exists

36 36 Health Outcomes vs Mold Sufficient evidence of a causal relationshipSufficient evidence of a causal relationship Sufficient evidence of an associationSufficient evidence of an association Limited or suggestive evidence of an associationLimited or suggestive evidence of an association Inadequate or insufficient evidence to determine whether an association existsInadequate or insufficient evidence to determine whether an association exists

37 37 Health Outcomes vs Mold Sufficient evidence of a causal relationship:Sufficient evidence of a causal relationship:

38 38 Health Outcomes vs Mold Sufficient evidence of a causal relationship:Sufficient evidence of a causal relationship: No outcomes met definition

39 39 Health Outcomes vs Mold Sufficient evidence of a causal relationshipSufficient evidence of a causal relationship Sufficient evidence of an associationSufficient evidence of an association Limited or suggestive evidence of an associationLimited or suggestive evidence of an association Inadequate or insufficient evidence to determine whether an association existsInadequate or insufficient evidence to determine whether an association exists

40 40 Health Outcomes vs Mold Sufficient evidence of an association:Sufficient evidence of an association: Upper respiratory tract symptoms Asthma in sensitized asthmatics Hypersensitivity pneumonitis (susceptible) WheezeCough

41 41 Health Outcomes vs Mold Sufficient evidence of a causal relationshipSufficient evidence of a causal relationship Sufficient evidence of an associationSufficient evidence of an association Limited or suggestive evidence of an associationLimited or suggestive evidence of an association Inadequate or insufficient evidence to determine whether an association existsInadequate or insufficient evidence to determine whether an association exists

42 42 Health Outcomes vs Mold Limited or suggestive evidence ofLimited or suggestive evidence of an association: Lower respiratory illness in otherwise- healthy children

43 43 Health Outcomes vs Mold Sufficient evidence of a causal relationshipSufficient evidence of a causal relationship Sufficient evidence of an associationSufficient evidence of an association Limited or suggestive evidence of an associationLimited or suggestive evidence of an association Inadequate or insufficient evidence to determine whether an association existsInadequate or insufficient evidence to determine whether an association exists

44 44 Health Outcomes vs Mold Inadequate or insufficient evidence to determine whether an association exists: 1/3Inadequate or insufficient evidence to determine whether an association exists: 1/3Dyspnea Airflow obstruction (otherwise healthy) Mucous membrane irritation syndrome Chronic obstructive pulmonary disease Inhalational fevers (non-occupational)

45 45 Health Outcomes vs Mold Inadequate or insufficient evidence to determine whether an association exists: 2/3Inadequate or insufficient evidence to determine whether an association exists: 2/3 Lower respiratory illness (healthy adults) Rheumatologic / other immune disease Acute idiopathic pulmonary hemorrhage Skin symptoms Asthma development

46 46 Health Outcomes vs Mold Inadequate or insufficient evidence to determine whether an association exists: 3/3Inadequate or insufficient evidence to determine whether an association exists: 3/3 Gastrointestinal tract problems Fatigue Neuropsychiatric symptoms Cancer Reproductive effects

47 47 “Toxic Mold”

48 48 Indoor Mold Molds blamed for variety of ailments and disabilitiesMolds blamed for variety of ailments and disabilities Subject of litigationSubject of litigation –Ballard case: $32 million

49 49 DPH Message

50 50 If It Looks Like Mold & Smells Like Mold…

51 51 Don’t Test! Find the water source and stop the leakingFind the water source and stop the leaking Discard water-damaged porous materialsDiscard water-damaged porous materials Clean non-porous surfaces with 10% bleach (1 part bleach + 9 parts water) – allow it to dry naturallyClean non-porous surfaces with 10% bleach (1 part bleach + 9 parts water) – allow it to dry naturally Never mix ammonia with bleachNever mix ammonia with bleach

52 52 Don’t Test! Ventilate – open windows/doors, and/or turn on air handling systemsVentilate – open windows/doors, and/or turn on air handling systems Keep relative humidity below 60% at all timesKeep relative humidity below 60% at all times –Use a dehumidifier in the basement, empty whenever needed –Buy a hygrometer to measure relative humidity to be sure dehumidifier is doing it’s job.

53 53 Why Are There No Standards For Indoor Mold? Personal Health StatusPersonal Health Status Types of FungiTypes of Fungi Concurrent ExposuresConcurrent Exposures Amount of ExposureAmount of Exposure Genetic PredispositionGenetic Predisposition AgeAge

54 54 Environmental Air Sampling Generally, waste of time & resourcesGenerally, waste of time & resources Will always show mold!Will always show mold!

55 55 What About Indoor vs. Outdoor Spore Counts? Unless there is a specific indoor source for specific microbes, indoor conc. will always be lower than outdoorsUnless there is a specific indoor source for specific microbes, indoor conc. will always be lower than outdoors Outdoor bioaerosols come indoors at rates dependent upon nature of ventilation to interiorOutdoor bioaerosols come indoors at rates dependent upon nature of ventilation to interior Naturally ventilated bldgs will have more orgs. from outdoor sources that tighter bldgsNaturally ventilated bldgs will have more orgs. from outdoor sources that tighter bldgs The I/O ratio is a function of ventilation, infiltration/exfiltration & other things not related to indoor mold growthThe I/O ratio is a function of ventilation, infiltration/exfiltration & other things not related to indoor mold growth

56 56 Real Data From a Home Spore trap results showing normal daily fluctuation What does it mean?

57 57 What Can the Provider Do? Take an environmental historyTake an environmental history –Typical questions Timing of symptoms (home, work, recreation)Timing of symptoms (home, work, recreation) Presence of moisture, carpetingPresence of moisture, carpeting Types of HVACTypes of HVAC Overall cleanlinessOverall cleanliness –Primers available from EPAEPA National Environmental Education FoundationNational Environmental Education Foundation

58 58 What Can the Provider Do? Point out normal exam findingsPoint out normal exam findings Explain the evidenceExplain the evidence –lack of causality Reassure parents and patientsReassure parents and patients

59 59 Putting Mold into Perspective EtiologyDeathsSourceYear Poisoning1,535AAPCC2008 Radon20,000EPA2010 Motor Vehicle Crashes34,000NHTSA2009

60 60 Summary Mold UbiquitousUbiquitous Requires waterRequires water No evidence for causal relationship with human illnessNo evidence for causal relationship with human illness Some evidence for association with selected illnessesSome evidence for association with selected illnesses

61 61 Take-home Message MedicalMedical –Most fungi NOT pathogenic to healthy humans EnvironmentalEnvironmental –Don’t ask for air sampling –Source reduction is most important –Call DPH w/ further concerns, i.e., environmental assessments

62 62 E-Resources CT Department of Public Health Department of Public Health Environmental Protection Agency Protection Agency Health CanadaHealth Canada Canada Mortgage and Housing Corp’s About Your House Series.Canada Mortgage and Housing Corp’s About Your House Series.

63 63 E-Resources Guidance for clinicians on the recognition and management of health effects related to mold exposure and moisture indoors. UCHC. Environmental and Occupational History. Chapter 3. In: Recognition And Management of Pesticide Poisonings. U.S Environmental Protection Agency. EPA 375-R March book.htm book.htm National Environmental Education Foundation Pediatric Environmental History Initiative: Pediatric Environmental History Primer Pediatric Environmental History Forms

64 64 Contact Us! Carl Baum, MDMarian L. Heyman, MT, MPH TOXI (8694)


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