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Indoor Air Quality: Mold in the schools By Chris Randolph, M.D. Associate Clinical Professor Yale Affiliated Hospitals Waterbury, CT.

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Presentation on theme: "Indoor Air Quality: Mold in the schools By Chris Randolph, M.D. Associate Clinical Professor Yale Affiliated Hospitals Waterbury, CT."— Presentation transcript:

1 Indoor Air Quality: Mold in the schools By Chris Randolph, M.D. Associate Clinical Professor Yale Affiliated Hospitals Waterbury, CT

2 Learning objectives: Outlines To familiarize the healthcare provider with: 1. Mold associated illness in schools: a. The Role of fungi in the Environment. b. The health impact on schools. c. The role of toxigenic fungi. 2. Diagnosis and remediation of mold in the school.

3 Definitions o Fungus  Gr sponge: ”Any of a large division of thallophytes including molds, mildew, mushrooms, rusts and smuts, which are parasites on living organisms or feed upon dead organic matter” o Reproduce by spores and lack chlorophyll, true roots, stems or leaves. (Webster’s New World Dictionary 3 rd college edition 1994 MacMillan p546-7) o Mold is “downy or furry growth on the surface of organic matter caused by fungi especially in presence of dampness or decay.” (Webster’s New World Dictionary 1994p873)

4 Definitions o Fungal Related Chemicals: o Metabolites: Toxins o Components or byproducts (VOC): Ergosterol, B(1-3) glucan, VOC (volatile organic compounds) o Mycotoxin: nonvolatile secondary metabolite of filamentous fungi that is toxic to vertebrates o Produced by many fungal spores and many toxins by same species i.e. Penicillium, Alternaria, Aspergillus, Fusarium as well as Stachybotrys. (Webster’s 1994/ Google) (Muilenberg M Current Views All/Imm 2004)

5 CASES: Mold Associated Illness in Water Damaged Schools  12 y/o w/f developed new onset “asthma” in a school adjacent to a waterfall.  Middle school children developed nonspecific rash, cough and/or influenza- like symptoms in a newly constructed school.  High School guidance counselors developed influenza - like symptoms  Remediation with decline in symptoms

6 Introduction: Ecology Mold represents a generally benign saprophyte Manufacture of antimicrobials to cheese Now health concern stifling home sales, increasing insurance, affecting schools and taxpayers as well with poorly documented health problems Texas insurance companies /Ed McMahon/Michael Jordan/School closures/State Farm and others eliminate coverage/millions in suits for attorneys (“Mold is gold”). ChapmanJA et al:Toxic mold:phantom riskvs science.Ann. Allergy2003:91;222-32

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

8 Ecology (Chapman 2003) Present 559 million years ago or earlier in peaceful coexistence Present 559 million years ago or earlier in peaceful coexistence Absorb water from soil, wood, decaying organic matter Absorb water from soil, wood, decaying organic matter Size microscopic to some of large, multi cellular organisms (6.5km2 in Washington State(3 counties): Armillaria ostoyae fungus) Size microscopic to some of large, multi cellular organisms (6.5km2 in Washington State(3 counties): Armillaria ostoyae fungus) Include 1.5 million species / 100,000 identified / 10 primary pathogens remainder saprobic Include 1.5 million species / 100,000 identified / 10 primary pathogens remainder saprobic Include toadstools, mildews, puffballs, yeasts, smut, rusts occupy 25% of earth biomass Include toadstools, mildews, puffballs, yeasts, smut, rusts occupy 25% of earth biomass Perfect and imperfect classes Perfect and imperfect classes Chapman JA,et al.Toxic mold:phantom risk Vs science.Annals Allergy,Asthma,Imm. 2003;91:

9 Ecology (Chapman 2003) Acremonium: produces toxin Acremonium: produces toxin Alternaria: carpets, textiles, window frames in building interiors Alternaria: carpets, textiles, window frames in building interiors Aspergillus flavus water damaged carpets, Aspergillus flavus water damaged carpets, Aspversicolor damp wood or wall paper glue Aspversicolor damp wood or wall paper glue Cladosp. in supply ducts Cladosp. in supply ducts Stachybotrys greenish black grows on cellulose Stachybotrys greenish black grows on cellulose Penicillium produce mycotoxins (Pexpansum, Pchrysogenum) Penicillium produce mycotoxins (Pexpansum, Pchrysogenum) Fusarium in humdifiers Fusarium in humdifiers Trichoderma in paper source of antibiotics toxic to humans Trichoderma in paper source of antibiotics toxic to humans Common indoor CommonOutdoor: Cladiosporium Basidiospores Penicillium Cladiosporium Aspergillus Ascospores Alternaria Aureobasidium Penicillium Aspergillus These require continuous O2, water, organic material and suitable temperature for growth. (HealthySchools Network,,Albany,NY. ChapmanJA et al AnnAll.2003;91:222-32

10 Fungi: growth conditions Atmospheric conditions : Atmospheric conditions : Require 70-90% relative humidity Require 70-90% relative humidity Grow optimally at o C Grow optimally at o C Wide variety host requirements Wide variety host requirements Some grow in hot, dry climate (xerophilic) Some grow in hot, dry climate (xerophilic) (Terr A.The role of mold in disease. AmAcadAllAsthmaImm meeting: San Francisco,California 3/04) (Terr A.The role of mold in disease. AmAcadAllAsthmaImm meeting: San Francisco,California 3/04)

11 Fungi: Habitat Outdoors: Ubiquitous: airborne globally except polar caps Outdoors: Ubiquitous: airborne globally except polar caps Indoors Indoors 30-70% of outdoors 30-70% of outdoors From outdoor penetration From outdoor penetration Or indoor source i.e. plant or garbage Or indoor source i.e. plant or garbage Primary host: plant especially crops Primary host: plant especially crops Saprophytic colonization or pathogenic (invade tissue) (Terr A. The role of mold in disease (and non-disease. AAAAI 3/04) Saprophytic colonization or pathogenic (invade tissue) (Terr A. The role of mold in disease (and non-disease. AAAAI 3/04)

12 IMPACT OF FUNGI ON HEALTH ? Agent Agent Source Source Pathway Pathway Adequate dose Adequate dose Outcome Outcome Null hypothesis: Damp, cold and moldy environments are not associated with poorer health. Null hypothesis: Damp, cold and moldy environments are not associated with poorer health.

13 Fungi o Areas of medical concern o Allergens o Infectivity o Toxins Terr A.The role of mold in disease and nondisease.AmAcadAllAsthma Imm. Meeting. SanFrancisco,California,3/04.

14 Toxic mold: phantom risk vs science Mold associated disease :need for controls and standards for exposure Mold associated disease :need for controls and standards for exposure Length exposure and individual sensitivity Length exposure and individual sensitivity 4 categories: 4 categories: Anecdotal evidence Anecdotal evidence Case studies Case studies Epidemiologic studies Epidemiologic studies Experimental evidence Experimental evidence Consequences of low level mold unknown Consequences of low level mold unknown Synergism with indoor aerosols Synergism with indoor aerosols Mold panic replace with science Mold panic replace with science Chapman et al Annals All2003;91: Burge,Annals 2003;91:

15

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

17 Indoor Air Quality in Schools (Dishop,2002) Airtight schools : ”modular format “was walled in w/o installation of adequate air circulation. (Morris,AB. Does design make a difference? Conf AIAComm Arch.Educ.AIA 1997) Airtight schools : ”modular format “was walled in w/o installation of adequate air circulation. (Morris,AB. Does design make a difference? Conf AIAComm Arch.Educ.AIA 1997) Poor maintenance leads to water injury medium for mold and fungal allergen Poor maintenance leads to water injury medium for mold and fungal allergen Sources indoor air quality: covered air supply, return ventilation, improperly maintained radiator and air filters, ins. sealed cleaning and maintenance chemicals. Wooden construction >concrete (Meklin T.AIHA Journal2003;64: ) Sources indoor air quality: covered air supply, return ventilation, improperly maintained radiator and air filters, ins. sealed cleaning and maintenance chemicals. Wooden construction >concrete (Meklin T.AIHA Journal2003;64: ) Other sources classroom pets, second hand smoke, Other sources classroom pets, second hand smoke, labs, copier, furnace room vents and ventilation labs, 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 with is unhealthy particularly for individuals with respiratory conditions. respiratory conditions. Dishop ML. Maintaining Environmental Cleanliness in School. Suppl JSchNursing 2002 (Oct):23-26

18 DishopML.Maintaining environmental cleanliness in school.SupplJSch Nurs October 2002.

19 Total airborne and viable fungi in schools Total airborne (Daisey et al Indoor Air 2003) and surface fungi in 13 classrooms in 6 Florida schools in 10 papers. Total airborne (Daisey et al Indoor Air 2003) and surface fungi in 13 classrooms in 6 Florida schools in 10 papers. Health complaints: stuffy sinuses, sore throat, respiratory illness, lethargy, itchy eyes and runny nose. Concentration >1000CFU/m3 in one complaint and non-complaint all others 1000CFU/m3 in one complaint and non-complaint all others <700CFU/m3 (Bates and Maffy,1996) Average and maximum total viable molds measured in 96 classrooms in 38 Swedish schools: 500CFU/M3 and 4,500CFU/m3 (Smedje et al, 1996, 1997) Average and maximum total viable molds measured in 96 classrooms in 38 Swedish schools: 500CFU/M3 and 4,500CFU/m3 (Smedje et al, 1996, 1997) Carpeted 1900CFU/g dust vs. bare floors 950CFU/g(p=.0.002) Carpeted 1900CFU/g dust vs. bare floors 950CFU/g(p=.0.002) Most prevalent genera: Penicillium, Fusarium, Alternaria and Cladosporium (Gravesen et al,1986) Most prevalent genera: Penicillium, Fusarium, Alternaria and Cladosporium (Gravesen et al,1986)

20 TerrA.JAll Clin Imm2004;113:221 Reference HistoryPhy. ExamAffected Bldg. Spec. mold(s) implicated Croft et al persons: cold, flu, sore throats, diarrhea, headaches, fatigue, dermatitis, alopecia, malaise Repeatedly Neg. HomeStachybotrys species Brunekreef et al US children (respiratory questionnaire) no control subjects Not doneHomesTotal molds, spores Platt et al UK children in 597 households: excess bad nerves, aching joints, nausea and vomiting, backache, blocked nose, fainting spells, constipation, breathlessness Not doneHomes measured Dampness or mold Total molds, spores Strachan et al Children with asthma wheezed more in homes with higher mold counts Yes, Spirometry Homes mold quantitation Total molds, spores Li & Hsu Children : questionnaire for self- report of dampness, mold & respiratory symptoms Not doneHomesTotal molds, spores Cooley et al Adult workers at 48 schools with indoor air quality complaints: no control subjects Not doneSchoolsPenicillium species, strachybotrys species Johanning et al, Descriptive study: 22 children and 125 adults with multiple symptoms Done, not reported Homes (no data on fungal exposure strachybotrys species Santilli & Rockwell Rhinitis questionnaire: 85 students & teachers Not done2 schoolsTotal molds, spores

21 Cooley J.Occupational Environ Med 1998:55:

22 Mold in Schools: Studies Allergy in form of RAST to molds and (+) PST particularly Aspergillus associated with IgG antibodies to molds found in mold damaged building. No association was found IgG to mold and exposure in school.(TaskinenTMetal.Allergy: (1)9-16) Allergy in form of RAST to molds and (+) PST particularly Aspergillus associated with IgG antibodies to molds found in mold damaged building. No association was found IgG to mold and exposure in school.(TaskinenTMetal.Allergy: (1)9-16) Sinusitis in teachers associated with elevated mold specific IgG to multiple fungi including Aspergillus and Stachybotrys with decrease in IgG on 2 year followup with sinusitis/bronchitis.(PatovirtaetalIJOMEH2003;16(3) Sinusitis in teachers associated with elevated mold specific IgG to multiple fungi including Aspergillus and Stachybotrys with decrease in IgG on 2 year followup with sinusitis/bronchitis.(PatovirtaetalIJOMEH2003;16(3) Association between elevated IgG to Penicillium notatum and E.amstelodami and moisture damage in school.(HyvarinenA.ArchEnHlth2003;58(5):275-83) Association between elevated IgG to Penicillium notatum and E.amstelodami and moisture damage in school.(HyvarinenA.ArchEnHlth2003;58(5):275-83) Mold in floor dust had no positive association with building related symptom.but 5/8 symptoms secondary to asthma,hayfever,recent airway infection or psychosocial factors.(Meyers:IndoorAir2004;14:65-72) Mold in floor dust had no positive association with building related symptom.but 5/8 symptoms secondary to asthma,hayfever,recent airway infection or psychosocial factors.(Meyers:IndoorAir2004;14:65-72) Childrens’ perception of symptoms increased after publicized that exposure to mold in schools related to cough,wheezing and joint pains.(Handal Get al Indoor Air 2004;14:87-91 ) Childrens’ perception of symptoms increased after publicized that exposure to mold in schools related to cough,wheezing and joint pains.(Handal Get al Indoor Air 2004;14:87-91 )

23 Mold in schools 33% U.S. public schools need extensive repair(6/96GAO) Two Connecticut public schools (Fairfield County) tested using multiple air quality testing methods with standard for healthy indoor environment for total mold spore counts 1,000spores/m3 In both schools counts were elevated (1 st : ,000 sp/m3, 2 nd sp/m3) with associated allergic symptoms. Both were remediated. The first school was demolished and rebuilt. Santilli et al :Ann Allergy Asthma Imm.2003;90:

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

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

26 Fungi: Environmental assessment Air sampling: examples Standard > 1000sp/ m3, 100 cfu/m3, 75% (I-O). Air sampling: examples Standard > 1000sp/ m3, 100 cfu/m3, 75% (I-O). 1. Viable: culture plates colony counts 2. Nonviable: spores (spores/m3) 3. Surface sample (swipe) Qualitative only 3. Surface sample (swipe) Qualitative only Multiple samples: agitation/indoor /outdoor Multiple samples: agitation/indoor /outdoor Good labs certified Good labs certified Terr A. The role of mold in disease and non disease, Amer, Acad All Asthma Imm Meeting San Francisco, California 3/04

27 Fungi: International distribution Total airborne spore population 1000x pollens Total airborne spore population 1000x pollens Outdoors: up to 50,000/m3 Outdoors: up to 50,000/m3 Indoors : up to 40,000/m3 Indoors : up to 40,000/m3 Moldy hay barns up to 1,600,000,000/m3 (Terr A lecture AAAAI SF 3/04) Moldy hay barns up to 1,600,000,000/m3 (Terr A lecture AAAAI SF 3/04)

28 Carpet SamplingsColony Forming Units/Gm Room ,500,000 Room ,120,000 Room 221 1,970,000 Wall Cavity SamplingsMold Spores/m3 Room ,666 Room ,667 Room ,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:

29 Figure 4 Results of ASHA testing indoor air quality at Mckinley Elementary School Fig 5 Results of Turner Environmental testing indoor air quality at Mckinley Elementary School

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

31 Some less common symptoms: fever, vomiting, nausea, nosebleeds, dizziness, memory loss, diarrhea and changes in behavior Mycotoxin related symptoms fever, vomiting, nausea, nosebleeds, dizziness, memory loss, diarrhea and changes in behavior Mycotoxin related symptoms MuilenbergML.Toxigenic fungi.Current Views in All Imm V;XXXII I/04. MedCollGeo.

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

33 Mold in schools  Skin prick test findings from moisture and mold damaged schools: Mold allergy in a 3 year follow up disappeared in 2 children and developed in 5.  5/6 of children with reactions >/= 3mm to molds had (+) response to other allergens  5 children had clinical atopy/2 asthma  All six children had been exposed to moisture and dampness in the school buildings  Most reactions to molds in child >14y with multiple SPT reactions to common allergens but no association with asthma Immonen Jet al Pediatric Allergy and Imm.:2001;12(2):87-94

34 Toxigenic Fungi M.L. Muilenberg Livestock exposures to mycotoxins Livestock exposures to mycotoxins Human food and mycotoxins Human food and mycotoxins The toxigenic fungi and their mycotoxins The toxigenic fungi and their mycotoxins Alternaria, Aspergillus, Fusarium, Penicillium, Stachybotrys Alternaria, Aspergillus, Fusarium, Penicillium, Stachybotrys Respiratory exposures to mycotoxins Respiratory exposures to mycotoxins Sampling and exposure Sampling and exposure Recommendations Recommendations Summary Summary Muilenberg M.Toxigenicfungi.Current Views in Allergy Immunology.2004; VolumeXXXII.Program4(January)Medical College of Georgia.

35 Mycotoxins (Etzel RA,JAMA 2002) AflatoxinsAspergillus FlavusCornGI/ Neuro Clavine alkaloidsClaviceps FusiformisMilletGI/ Drow. ErgometrineC. Purpurea (St. A Fire)BarleyGI/ N/ Gang FumonismsFusarium (horse, swine)CornN/P/Death CyclopiazonicAspergillusMilletGI/ Giddy OchratoxinPenicillum / AspGrainsRenal T 2 ToxinFusarium (cattle)CornAbortion TrichothecenesFusarium / AspWheatGI TremorgensAsp/ Pen/ Muc/ Rh/ Cep Grass/ Alf GI/ N SlaframineRhizo (horse, cattle, sheep) Gr/ WhGI/ N Etzel RA.Mycotoxins.JnlAmer.Med Ass.2002;287(4):425-7.

36 Human Stachybotryotoxicosis By ingestion: 1930’s in Siberia horses fed moldy grain developed agranulocytosis, GI hemorrhage and ulceration similar reports in sheep, other animals and farmers. By ingestion: 1930’s in Siberia horses fed moldy grain developed agranulocytosis, GI hemorrhage and ulceration similar reports in sheep, other animals and farmers USSR Academy of Sciences (VG Drobotko) 1942 USSR Academy of Sciences (VG Drobotko) By inhalation never proven in humans would require massive doses seen in agricultural or remediation settings (x10 to 6 th power or more spores/mm3) By inhalation never proven in humans would require massive doses seen in agricultural or remediation settings (x10 to 6 th power or more spores/mm3) 2.1 x 106 spores / m3 for infant 15.3 x 106spores /m3 for an adult. 2.1 x 106 spores / m3 for infant 15.3 x 106spores /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 Current Views Allergy Immunology 2004; Volume XXXII. Prog4. Med. CollGeo. (Terr A. Mold in disease and non-disease AAAAI3/2004)(Muilenberg M Current Views Allergy Immunology 2004; Volume XXXII. Prog4. Med. CollGeo.

37 Cleveland AIPH Case/Control Study Criticisms re: Conclusion about Importance of Stachybotrys Case/Control characteristics: race, gender, birth weight, breastfeeding, smoking, were significantly different Case/Control characteristics: race, gender, birth weight, breastfeeding, smoking, were significantly different Other members of the family were not sick Other members of the family were not sick CDC disputed calculation of Stachybotrys exposure Odds Ratios (risk for IPH); should be 1.5, not 9.8 CDC disputed calculation of Stachybotrys exposure Odds Ratios (risk for IPH); should be 1.5, not 9.8 Imputed fungal value used in one home; dropping this from model reduced fungal-IPH OR from 5.5 to 1.9 Imputed fungal value used in one home; dropping this from model reduced fungal-IPH OR from 5.5 to 1.9 Bias was alleged in collection of surface fungal samples (oversampling in case homes) Bias was alleged in collection of surface fungal samples (oversampling in case homes) CDC.Notice to readers.Availability of case definition for acute idiopathic pulmon- Ary hemorrhage in infants.Atlanta,Georgia:CDCand Prev.2001:50(23):494-5

38 Summary continued CDC investigation 1999 CDC investigation 1999 Conclusion: Conclusion: A possible association between acute pulmonary hemorrhage…and (mold) exposure …was not proven (CDC.Report of working group on pulm. hemorrhage and hemosiderosis, CDC and Prevention,1999) A possible association between acute pulmonary hemorrhage…and (mold) exposure …was not proven (CDC.Report of working group on pulm. hemorrhage and hemosiderosis, CDC and Prevention,1999) Human diseases from mold: Human diseases from mold: Specific molds produce infectious or allergic disease Specific molds produce infectious or allergic disease Toxic conditions from inhalation of mold spores is unproven. (Terr AThe role of mold in disease and non- disease. AAAAI 3/04) Toxic conditions from inhalation of mold spores is unproven. (Terr AThe role of mold in disease and non- disease. AAAAI 3/04) Current scientific evidence does not support…that human health has been adversely affected by inhaled mycotoxins in home, school or office environments. ACOEM JOEM 2003;45(5): Current scientific evidence does not support…that human health has been adversely affected by inhaled mycotoxins in home, school or office environments. ACOEM JOEM 2003;45(5):470-78

39 DIAGNOSIS & REMEDIATION  NHLBI:  Goals for Healthy School Environment  Keep temperature and humidity appropriate  Maintain HVAC systems  Dry up damp and wet areas within 1-2 days  Minimize exposure to triggers: smoke, chemical vapors, chalk dust, mold, fumes and animals.

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41 Approach for Patient o Log of walk through school : check for mold or water damage, stagnant water, inadequate ventilation, air intake grills o Check ceilings, tiles, walls looking for water stains including inside closets, boxes and behind furniture o Damp musty smell or visible colored deposits green, brown, yellow or black should be taken care of immediately to prevent spreading o Tell your doctor (Healthy Schools Network, Inc:Albany,NY

42 Evaluation of Building related illness by specialist  Comprehensive history: nature of symptoms, home, work environment, medical and family history.  Physical exam: signs of systemic fungal, Tb and pneumocystis pneumonia  Atopy: skin and serologic testing and PFT pre and post bronchodilator  Chest x-ray /CT of chest  Supportive testing serologic Ig to fungi, for humoral and cell med immunity and pneumonitis  Environmental assess: walk through and sample measurement of vacuumed dust sample and water damaged areas by prof. hygienist  Measurement of total symptom scores inside and outside  Pre-bronchodilator and post-bronchodilator measurement of spirometry inside and outside home or workplace every 2-4 hrs while awake and correlate with environmental exposure measurement.  Tools for schools EPA (Environmental Protection Agency)  OSHA (Occupational Safety and Health Administration) Chapman et al Annals Allergy,Asthma,Immunol2003;91:

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44 MethodAdvantageDisadvantageImplications Visual id air sampleRapid for airborne exposure sensitive No species,laboriousInhaled species associate disease CultureIdentify species assay for mycotoxins Laborious must grow on media not sensitive Inhaled spores cause disease QuestionaireInexpensiveNot specific or validated Allergen ImmunoassayVery sensitive specific for genera Monoclonal too specific Measures allergic potential MycotoxinsToxic potental of exposure Assay difficult to reproduce: EIA Chromotography Organ toxicity ErgosterolFungal MassNot useful for taxaNone EPSsTo identify generaNone B(1-3) glucanFungal MassNon-fungal sources affect Inflammation VOCs(Volatile organic compounds) PCR need standards Specific for taxaNon-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:S

45 Results Report Scope of work Scope of work Site physical description Site physical description Review of mechanical systems: HVAC, etc Review of mechanical systems: HVAC, etc Sample location and circumstances Sample location and circumstances Summary analytic results and recommendations including walk-through Summary analytic results and recommendations including walk-through Analytic reports: IAQ measurements with spore counts by genus indoor and outdoor ratio, rooms sampled, bulk and surface samples, vacuum dust samples in CFU/gm or m2,instruments used, lab reports (Portnoy J Allergy Clin Imm.2004;113(2): Analytic reports: IAQ measurements with spore counts by genus indoor and outdoor ratio, rooms sampled, bulk and surface samples, vacuum dust samples in CFU/gm or m2,instruments used, lab reports (Portnoy J Allergy Clin Imm.2004;113(2):

46 Assessment and remediation of indoor fungi Prompt remediation of contaminated material and infrastructure repair. Prevent contamination through proper building, heating, ventilation, air conditioning (HVAC) maintenance and repair of water damage. (Tools) More research needed to link health outcomes and mycotoxins. Env assessment: visual inspection HVAC, ceilings, gypsum wallboard, paper and cellulose containing surfaces. Indoor and outdoor comparisons (no standard or human dose response) range upward from 100CFU/m3.School closures and rebuilding. Remediation of water damage or condensation immediately (RH<60%) 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 WWW Concern little science to support public reaction (“black box”). Chapman et al.Toxic mold:phantom risk vs science.Annals Allergy Asthma,Immunol 91:

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48 Checklist for mold remediation Investigate and assess moisture and mold problems: Investigate and assess moisture and mold problems: Evaluate size of mold infestation (ft2) Evaluate size of mold infestation (ft2) Eradicate small deposits, remediation manager for medium to large size mold problem. Eradicate small deposits, remediation manager for medium to large size mold problem. Identify source of moisture problems Identify source of moisture problems Evaluate air ducts and air handling units Evaluate air ducts and air handling units Consult professional throughout (>10sqft) Consult professional throughout (>10sqft) EPA. Mold remediation in schools and commercial buildings. EPA 402-K /01

49 Checklist for mold remediation Communicate with building occupants at all times with designated person Communicate with building occupants at all times with designated person Plan remediation: trained remediation personnel, proper containment equipment and personal protective equipment, cleanup mold items and drying non-moldy materials within 48 hours. Plan remediation: trained remediation personnel, proper containment equipment and personal protective equipment, cleanup mold items and drying non-moldy materials within 48 hours. Remediation moisture and mold problems: Remediation moisture and mold problems: Fix moisture problems including maintenance and/or repair Fix moisture problems including maintenance and/or repair Eliminate porous material infested with mold that can’t be cleaned. Eliminate porous material infested with mold that can’t be cleaned. EPA.Mold remediation in schools and commercial buildings.EPA402-K /01.

50 Fungi: State of knowledge Fungi estimated (international) >1,000,000 sp Fungi characterized >70,000 sp Fungi assoc. resp. allergy >80 species Fungal allergens cloned * >70 allergens Genera of cloned fungi 11 Controlled IT studies 4 Fungal species tested in IT 2 (Alternaria alternata / Cladosporium, herbarum) Helbling A,et al:Current Allergy and Asthma Reports 2003;3:

51 Conclusions Rigorous prospective studies linking exposure to mold in water damaged school environments and subsequent human disease need to be done. Rigorous prospective studies linking exposure to mold in water damaged school environments and subsequent human disease need to be done. In the interim if after careful inspection more extensive water damage (>10 sq ft) is suggested especially with symptomatic personnel, then professional investigation by OSHA and industrial hygienist with micro and bulk sampling as well as appropriate air sampling indoor and outdoor is recommended. In the interim if after careful inspection more extensive water damage (>10 sq ft) is suggested especially with symptomatic personnel, then professional investigation by OSHA and industrial hygienist with micro and bulk sampling as well as appropriate air sampling indoor and outdoor is recommended. Remediation to correct existing and prevent further water damage should then be done by professionals. Remediation to correct existing and prevent further water damage should then be done by professionals.

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53 Resource list: EPA IAQ (Indoor air quality) in schools IAQ (Indoor air quality) in schools Mold remediation in schools Mold remediation in schools Indoor air quality(IAQ)home page Indoor air quality(IAQ)home page EPA IAQ Clearinghouse EPA IAQ Clearinghouse

54 Mold Remediation Labs Aerobiology Instruction & Research 465 Washington St., #1 Brookline, MA Aerobiology Lab Assoc., Inc Sunrise Valley Dr, Suite 1250 Reston, VA Environmental Microbiology Lab Scripps Summit Ct., Ste. 103 San Diego, CA P&K/Aerotech Microbiology Services, Inc Olney Ave. Cherry Hill, NJ (RT-PCR; culture, spore ID) Environmental Testing and Technology, Inc Mt. Hukee Ave. San Diego, CA Air Quality Sciences, Inc. Atlanta, GA (770) EMSL Analytical, Inc. N. Miami Beach, FL (800)

55 References 1. Dales RE, Cakmak S, Burnett RT et al. Influence of ambient fungal spores on emergency visits for asthma to a regional children’s hospital. Am J Respir Crit Care Med.2000;162(6): Platts-Mills TAE Solomon W. Aerobiology and inhalant allergens. Chapter 19.Allergy:PrinciplesandPractice.ed E Middleton, CE Reed, EF Ellis, NFAtkinson et al. Fourth edition Volume 1 :Mosby St Louis,Missouri,1993: Belkin L. Haunted by mold. NY Times Magazine August 12, 2001 Late ed. Section 6,Column1,p28(16pages) 4. Webster’s New World Dictionary.Copyright 1994,Simon and Schuster,Macmillan New York, New York p873.

56 References 5.Biology 5 thed NACampbell, JB Reece, LG Mitchell. Chapter 31.Fungi. P Addison Wesley Longman, Inc 1999 Menlo Park,California 6. Terr A. Role of mold in disease and nondisease. AAAAI meeting SanFranciso 3/ Chapman JA,TerrAI, Jacobs et al. Toxic mold: phantom risk vs science. Annals Allergy 2003;91:

57 References 8. Burge HA Fungi: Toxi killers or unavoidable nuisance. Annals Allergy, Asthma, Immunol 2001:87(Suppl) Burge HA. Bioaerosols and the scientific method. Ann Allergy Asthma Immunol 2003:91: Healthy Schools Network. Albany, NY 11. Bush RK,Prochnau JJ. Alternaria-induced asthma. J Allergy Clin Immunol 2004;113:

58 References continued 12. Dishop ML. Maintaining environmental cleanliness in school. Supplement in the Jnl School Nursing.2002(October): Morris,AB.Ed.(1997).Does design make a difference: A conference of the AIA Committee on Architecture for Education. Scottsdale:American Institute of Architects. 14. Meklin T, Hyvarinen A, Toivola M, etal. Effect of building frame and moisture damage on microbiological indoor air quality in school buildings. AIHA J;a J Sci Occ Env Hlth Safety. 2003;64(1): Terr AI. Are indoor molds causing a new disease? J Allergy Clin Immunol 2004;113:221-6.

59 References continued 21. Cuijpers CE, Swaen GM, Wessling G, et al. Adverse effects of the indoor environment on respiratory health in primary school children. Environ.Res 1995;68; Garrett MH,Rayment PR, Hooper MA et al. Indoor airborne fungi, spores, house dampness and associations with environmental factorsand respiratory health in children. Clin Exp. Allergy. 1998:28; Koskinen OM, Husman TM, Hyvarinen AM.Respiratory symptoms and infections among children in a day –care-center with mold problems. Indoor Air-Int J Indoor Air Quality Climate.1995;5: Kosknen OM, Husman TM, Hyvarinen AM, et al. Two moldy day- care centers :a follow-up study of respiratory symptoms and infections. Indoor Air-Int J Indoor Air Quality Climate. 1997;7: Douwes J. Respiratory health effects of indoor microbial exposure. A contribution to the development of exposure assessment methods. Thesis,Wageningen.1998:1-171.

60 References 26. Meyer HW, Wurtz H, Suadicani P, et al. Molds in floor dust and building related symptoms in adolescent school children. Indoor Air 2003;14: Handal G, Leiner MA, Cabrera M etal. Children symptoms before and after knowing about an indoor fungal contamination. Indoor Air 2004;14: Santilli J, Rockwell W. Fungal contamination of elementary schools :a new environmental hazard: Ann Allergy Asthma Immunol 2003;90: O’Connor GT, et al Airborne fungi in the homes of children with asthma in low income urban communities: The Inner City Asthma. J Allergy Clin Innumol 2004:114:599: Daisy JM, Angell WJ, Apte MG. Indoor air quality, ventilation, and health symptoms in school :An analysis of existing information.Indoor Air 2003;13(1): Amr S, BollingerMS, Meyers M, et al. Environmental allergy and asthma in urban elementary schools. Ann Allergy Asthma Immunol 2003;90(1): Immonen J, MeklinT,Taskinen T, et al.Skin prick test findings in students from moisture and mould –damaged schools: a 3 year follow up study. Pediatric Allergy and Immunology.2001;12(2): Savilahti R, Utti J,Roto P, et al. Increased prevalence of atopy among children exposed to mold in a school building. Allergy 2001;56(2): Muilenberg ML. Toxigenic fungi. Current Views in Allergy Immunology. Volume XXXII:1/04.MedicalCollege Georgia

61 References continued 35. Etzel RA. Mycotoxins. JAMA 2002;287(4): Etzel RA, Balk SJ, Bearer C Fetal. Committee on Environmental Health American Academy of Pediatrics. Toxic effects of indoor molds. Pediatrics 1998;4: Montana E,Etzel RA,Allan T, et al.Environmental risk factors associated with pediatric idiopathic pulmonary hemorrhage and hemosiderosis in a Cleveland community. Pediatrics 1997;99(1): CDC. Reportof the CDC Working Group on Pulmonary Hemorrhage and Hemosiderosis. Atlant,Georgia:CDCand Prevention CDC.Notice to readers. Availablity of case definition for acute idiopathic pulmonary hemorrhage in infants.Atlanta, Georgia :Center for Disease Control and Prevention;2001;50(23): Kuhn DM, Ghannoun MA.Indoor mold, toxigenic fungi and Stachybotrys chartarum: Infectious disease perspective. Clinical Microbiology Reviews 2003;16(1): Bennett JW,Klich M. Mycotoxins Clinical Microbiology Reviews 2003;16(3): Robbins CA, Swenson LJ, NealleyML et al Health effects of mycotoxins in indoor air :a critical review.Applied Occupational and Environmental Hygiene2000;15(10): Hardin BD, Kelman BJ, Saxon A. Adverse human health effects associated with molds in the indoor environment (statement). Journal Occupational and Environmental Medicine2003:45(5):470-78

62 References continued 44. Bush RK, Portnoy J. The role of abatement of fungal allergens in. allergic diseases.JAllergy Clin Immunol 2001;107:S allergic diseases.JAllergy Clin Immunol 2001;107:S Meklin T, Haugland RA, ReponenT, et al. Quantitative PCR analysis of house dust can reveal abnormal mold conditions. J EnvironMonit 2004;6(7): Kauffman HF, Van der Heide S. Exposure,sensitization,and mechanisms of fungus-induced asthma.Current Allergy and Asthma Reports 2003;3: Heibling A, Reimers A.Immunotherapy in fungal allergy. Current Allergy and Asthma Reports 2003;90: Eggleston P. Environmental control for fungal allergen exposure. Current Allergy and Asthma Reports 2003;3(5): EPA.Mold remediation in schools and commercial buildings.EPA 402-K-001 March 2001USEPA


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