Presentation on theme: "Indoor Air Quality: Mold in the schools"— Presentation transcript:
1Indoor Air Quality: Mold in the schools By Chris Randolph, M.D.Associate Clinical ProfessorYale Affiliated HospitalsWaterbury, CT
2Learning objectives: Outlines To familiarize the healthcare provider with:Mold associated illness in schools:The Role of fungi in the Environment.The health impact on schools.The role of toxigenic fungi.Diagnosis and remediation of mold in the school.
3DefinitionsFungus 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”Reproduce by spores and lack chlorophyll, true roots, stems or leaves. (Webster’s New World Dictionary 3rd college edition 1994 MacMillan p546-7)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)
4Definitions Fungal Related Chemicals: Metabolites: Toxins Components or byproducts (VOC): Ergosterol, B(1-3) glucan, VOC (volatile organic compounds)Mycotoxin: nonvolatile secondary metabolite of filamentous fungi that is toxic to vertebratesProduced 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)
5CASES: 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 symptomsRemediation with decline in symptoms
6Introduction: Ecology Mold represents a generally benign saprophyteManufacture of antimicrobials to cheeseNow health concern stifling home sales, increasing insurance, affecting schools and taxpayers as well with poorly documented health problemsTexas 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
7Belkin L.Haunted by mold.NYTimes Magazine8/12/2001p28
8Ecology (Chapman 2003)Present 559 million years ago or earlier in peaceful coexistenceAbsorb water from soil, wood, decaying organic matterSize 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 saprobicInclude toadstools, mildews, puffballs, yeasts, smut, rusts occupy 25% of earth biomassPerfect and imperfect classesChapman JA,et al.Toxic mold:phantom riskVs science.Annals Allergy,Asthma,Imm.2003;91:
9Ecology (Chapman 2003) Common indoor CommonOutdoor: Cladiosporium BasidiosporesPenicillium CladiosporiumAspergillus AscosporesAlternaria AlternariaAureobasidium Penicillium AspergillusThese require continuous O2,water, organic material andsuitable temperature for growth.Acremonium: produces toxinAlternaria: carpets, textiles, window frames in building interiorsAspergillus flavus water damaged carpets,Aspversicolor damp wood or wall paper glueCladosp. in supply ductsStachybotrys greenish black grows on cellulosePenicillium produce mycotoxins (Pexpansum, Pchrysogenum)Fusarium in humdifiersTrichoderma in paper source of antibiotics toxic to humansChapmanJA et al AnnAll.2003;91:222-32(HealthySchools Network,,Albany,NY.
10Fungi: growth conditions Atmospheric conditions :Require 70-90% relative humidityGrow optimally at 20-40o CWide variety host requirementsSome grow in hot, dry climate (xerophilic)(Terr A.The role of mold in disease. AmAcadAllAsthmaImm meeting: San Francisco,California 3/04)
11Fungi: HabitatOutdoors: Ubiquitous: airborne globally except polar capsIndoors30-70% of outdoorsFrom outdoor penetrationOr indoor source i.e. plant or garbagePrimary host: plant especially cropsSaprophytic colonization or pathogenic (invade tissue) (Terr A. The role of mold in disease (and non-disease. AAAAI 3/04)
12IMPACT OF FUNGI ON HEALTH ? AgentSourcePathwayAdequate doseOutcomeNull hypothesis: Damp, cold and moldy environments are not associated with poorer health.
13Fungi Areas of medical concern Allergens Infectivity Toxins Terr A.The role of mold in disease and nondisease.AmAcadAllAsthmaImm. Meeting. SanFrancisco ,California ,3/04.
14Toxic mold: phantom risk vs science Mold associated disease :need for controls and standards for exposureLength exposure and individual sensitivity4 categories:Anecdotal evidenceCase studiesEpidemiologic studiesExperimental evidenceConsequences of low level mold unknownSynergism with indoor aerosolsMold panic replace with scienceBurge,Annals 2003;91:Chapman et al Annals All2003;91:
16Dales RE,CakmakS,BurnettRT,et al Dales RE,CakmakS,BurnettRT,et al.Am J RespCrit Care Med 2000;162(6):
17Indoor 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)Poor maintenance leads to water injury medium for mold and fungal allergenSources 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,labs, copier, furnace room vents and ventilationsystem, water and moisture injury, eating facilities,upholstered furniture.Children most vulnerable particularly with allergicrhinitis and asthma per Institute of medicinebecause they are low to ground have less bodymass and breath more rapidly.AAP Statement: Damp mold ridden environmentis unhealthy particularly for individuals withrespiratory conditions.Dishop ML. Maintaining Environmental Cleanliness in School. Suppl JSchNursing 2002 (Oct):23-26
18DishopML. Maintaining environmental cleanliness in school DishopML.Maintaining environmental cleanliness in school.SupplJSch NursOctober 2002.
19Total 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.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 <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)Carpeted 1900CFU/g dust vs. bare floors 950CFU/g(p=.0.002)Most prevalent genera: Penicillium, Fusarium, Alternaria and Cladosporium (Gravesen et al,1986)
20Spec. mold(s) implicated ReferenceHistoryPhy. ExamAffected Bldg.Spec. mold(s) implicatedCroft et al5 persons: cold, flu, sore throats, diarrhea, headaches, fatigue, dermatitis, alopecia, malaiseRepeatedly Neg.HomeStachybotrys speciesBrunekreef et al6273 US children (respiratory questionnaire) no control subjectsNot doneHomesTotal molds, sporesPlatt et al1169 UK children in 597 households: excess bad nerves, aching joints, nausea and vomiting, backache, blocked nose, fainting spells, constipation, breathlessnessHomes measured Dampness or moldStrachan et alChildren with asthma wheezed more in homes with higher mold countsYes, SpirometryHomes mold quantitationLi & Hsu1370 Children : questionnaire for self-report of dampness, mold & respiratory symptomsCooley et al622 Adult workers at 48 schools with indoor air quality complaints: no control subjectsSchoolsPenicillium species, strachybotrys speciesJohanning et al,Descriptive study: 22 children and 125 adults with multiple symptomsDone, not reportedHomes (no data on fungal exposurestrachybotrys speciesSantilli & RockwellRhinitis questionnaire: 85 students & teachers2 schoolsTerrA.JAll Clin Imm2004;113:221
21Cooley J.Occupational Environ Med 1998:55:579-584
22Mold 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)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)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 )
23Mold 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/m3In both schools counts were elevated (1st : ,000 sp/m3, 2nd 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:
24Santilli J et al. Fungal contamination of elementary schools: a new environmental hazard.Ann Allergy Asthma Imm2003;90:203-8.
25Santilli J etal.Fungal contamination of elementary schools:a new environmental hazard .Ann Allergy Asthma Immunol 2003;90:203-8
26Fungi: Environmental assessment Air sampling: examples Standard > 1000sp/ m3, 100 cfu/m3, 75% (I-O).1. Viable: culture plates colony counts2. Nonviable: spores (spores/m3)3. Surface sample (swipe) Qualitative onlyMultiple samples: agitation/indoor /outdoorGood labs certifiedTerr A. The role of mold in disease and non disease, Amer, Acad All Asthma ImmMeeting San Francisco, California 3/04
27Fungi: International distribution Total airborne spore population 1000x pollensOutdoors: up to 50,000/m3Indoors : up to 40,000/m3Moldy hay barns up to 1,600,000,000/m3 (Terr A lecture AAAAI SF 3/04)
28Colony Forming Units/Gm Table 1 Turner Environmental’s Testing of Mckinley Elementary School Revealed Severe Mold Contamination of the Wall Cavities and RugsCarpet SamplingsColony Forming Units/GmRoom 117108,500,000Room 11820,120,000Room 2211,970,000Wall Cavity SamplingsMold Spores/m3Room 107156,666106,667Room 121120,000Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:
29Figure 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 SchoolFungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:
30Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003;90:
31Some less common symptoms: fever, vomiting, nausea, nosebleeds, dizziness, memory loss, diarrhea and changes in behavior Mycotoxin related symptomsMuilenbergML.Toxigenic fungi.Current Views in All Imm V;XXXII I/04. MedCollGeo.
32Amr S et al.Environmental Allergens and Asthma in Urban Elementary Schools. Ann Allergy Asthma Immunol 2003;90:34-40
33Mold in schoolsSkin 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 allergens5 children had clinical atopy/2 asthmaAll six children had been exposed to moisture and dampness in the school buildingsMost reactions to molds in child >14y with multiple SPT reactions to common allergens but no association with asthmaImmonen Jet al Pediatric Allergy and Imm.:2001;12(2):87-94
34Toxigenic Fungi M.L. Muilenberg Livestock exposures to mycotoxinsHuman food and mycotoxinsThe toxigenic fungi and their mycotoxinsAlternaria, Aspergillus, Fusarium, Penicillium, StachybotrysRespiratory exposures to mycotoxinsSampling and exposureRecommendationsSummaryMuilenberg M.Toxigenicfungi .Current Views in Allergy Immunology.2004;VolumeXXXII.Program4(January)Medical College of Georgia.
36Human 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.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 6th power or more spores/mm3)2.1 x 106 spores / m3 for infant 15.3 x 106spores /m3 for an adult.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.
37Cleveland AIPH Case/Control Study Criticisms re: Conclusion about Importance of Stachybotrys Case/Control characteristics: race, gender, birth weight, breastfeeding, smoking, were significantly differentOther members of the family were not sickCDC disputed calculation of Stachybotrys exposure Odds Ratios (risk for IPH); should be 1.5, not 9.8Imputed fungal value used in one home; dropping this from model reduced fungal-IPH OR from 5.5 to 1.9Bias 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
38Summary continued CDC investigation 1999 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)Human diseases from mold:Specific molds produce infectious or allergic diseaseToxic 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):470-78
39DIAGNOSIS & REMEDIATION NHLBI:Goals for Healthy School EnvironmentKeep temperature and humidity appropriateMaintain HVAC systemsDry up damp and wet areas within 1-2 daysMinimize exposure to triggers: smoke, chemical vapors, chalk dust, mold, fumes and animals.
41Approach for PatientLog of walk through school : check for mold or water damage, stagnant water, inadequate ventilation, air intake grillsCheck ceilings, tiles, walls looking for water stains including inside closets, boxes and behind furnitureDamp musty smell or visible colored deposits green, brown, yellow or black should be taken care of immediately to prevent spreadingTell your doctor(Healthy Schools Network, Inc:Albany,NY
42Evaluation 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 pneumoniaAtopy: skin and serologic testing and PFT pre and post bronchodilatorChest x-ray /CT of chestSupportive testing serologic Ig to fungi, for humoral and cell med immunity and pneumonitisEnvironmental assess: walk through and sample measurement of vacuumed dust sample and water damaged areas by prof. hygienistMeasurement of total symptom scores inside and outsidePre-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:
44TABLE : METHODS FOR IDENTIFICATION OF INDOOR FUNGAL EXPOSURE AdvantageDisadvantageImplicationsVisual id air sampleRapid for airborne exposure sensitiveNo species,laboriousInhaled species associate diseaseCultureIdentify species assay for mycotoxinsLaborious must grow on media not sensitiveInhaled spores cause diseaseQuestionaireInexpensiveNot specific or validatedAllergen ImmunoassayVery sensitive specific for generaMonoclonal too specificMeasures allergic potentialMycotoxinsToxic potental of exposureAssay difficult to reproduce: EIA ChromotographyOrgan toxicityErgosterolFungal MassNot useful for taxaNoneEPSsTo identify generaB(1-3) glucanNon-fungal sources affectInflammationVOCs(Volatile organic compounds)PCR need standardsSpecific for taxaIrritantBUSH R,PORTNOY J.The role and abatement of fungal allergens in allergic disease.JALLERGY CLIN IMMUNOL2001;107:S
45Results Report Scope of work Site physical description Review of mechanical systems: HVAC, etcSample location and circumstancesSummary analytic results and recommendations including walk-throughAnalytic 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):
46Assessment 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 WWWConcern little science to support public reaction (“black box”).Chapman et al .Toxic mold:phantom risk vs science.Annals Allergy Asthma ,Immunol 91:
48Checklist for mold remediation Investigate and assess moisture and mold problems:Evaluate size of mold infestation (ft2)Eradicate small deposits, remediation manager for medium to large size mold problem.Identify source of moisture problemsEvaluate air ducts and air handling unitsConsult professional throughout (>10sqft)EPA. Mold remediation in schools and commercial buildings. EPA 402-K /01
49Checklist for mold remediation Communicate with building occupants at all times with designated personPlan 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:Fix moisture problems including maintenance and/or repairEliminate porous material infested with mold that can’t be cleaned.EPA.Mold remediation in schools and commercial buildings .EPA402-K /01.
50Fungi: State of knowledge Fungi estimated (international) >1,000,000 spFungi characterized >70,000 spFungi assoc. resp. allergy >80 speciesFungal allergens cloned * >70 allergensGenera of cloned fungiControlled IT studiesFungal species tested in IT(Alternaria alternata / Cladosporium, herbarum)Helbling A,et al:Current Allergy and Asthma Reports 2003;3:
51ConclusionsRigorous 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.Remediation to correct existing and prevent further water damage should then be done by professionals.
53Resource list: EPAIAQ (Indoor air quality) in schoolsMold remediation in schoolsIndoor air quality(IAQ)home pageEPA IAQ Clearinghouse
54Mold Remediation LabsAerobiology 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 92131P&K/Aerotech Microbiology Services, Inc Olney Ave. Cherry Hill, NJ 08003 (RT-PCR; culture, spore ID)Environmental Testing and Technology, Inc Mt. Hukee Ave. San Diego, CA 92117Air Quality Sciences, Inc.Atlanta, GA(770)EMSL Analytical, Inc.N. Miami Beach, FL(800)
55ReferencesDales 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)Webster’s New World Dictionary .Copyright 1994,Simon and Schuster ,Macmillan New York, New York p873.
56References5. Biology 5 thed NACampbell, JB Reece , LG Mitchell. Chapter 31.Fungi. P Addison Wesley Longman, Inc 1999 Menlo Park ,California6. Terr A. Role of mold in disease and nondisease. AAAAI meeting SanFranciso 3/04.7. Chapman JA,TerrAI, Jacobs et al. Toxic mold: phantom risk vs science. Annals Allergy 2003;91:
57References8. Burge HA Fungi: Toxi killers or unavoidable nuisance. Annals Allergy, Asthma, Immunol 2001:87(Suppl)9. Burge HA. Bioaerosols and the scientific method. Ann Allergy Asthma Immunol 2003:91:10. Healthy Schools Network. Albany, NY11. Bush RK ,Prochnau JJ. Alternaria-induced asthma. J Allergy Clin Immunol 2004;113:
58References continued12. Dishop ML. Maintaining environmental cleanliness in school. Supplement in the Jnl School Nursing .2002(October):23-2613. 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):15. Terr AI. Are indoor molds causing a new disease? J Allergy Clin Immunol 2004;113:221-6.
59References continuedCuijpers CE, Swaen GM, Wessling G, et al. Adverse effects of the indoor environment on respiratory health in primary school children. Environ.Res 1995;68;11-23.22. 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;23. 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;5:3-924. 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;7:25. Douwes J. Respiratory health effects of indoor microbial exposure. A contribution to the development of exposure assessment methods. Thesis,Wageningen .1998:1-171.
60References26. Meyer HW, Wurtz H, Suadicani P, et al. Molds in floor dust and building related symptoms in adolescent school children. Indoor Air 2003;14:65-7227. Handal G, Leiner MA, Cabrera M etal. Children symptoms before and after knowing about an indoor fungal contamination. Indoor Air 2004;14:87-91.28. Santilli J, Rockwell W. Fungal contamination of elementary schools :a new environmental hazard: Ann Allergy Asthma Immunol 2003;90:203-8.29. 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 2004:114:599:60630. 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):53-6431. Amr S, BollingerMS, Meyers M, et al. Environmental allergy and asthma in urban elementary schools. Ann Allergy Asthma Immunol 2003;90(1):34-40.32. 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):87-94.33. 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):175-9.34. Muilenberg ML. Toxigenic fungi. Current Views in Allergy Immunology.Volume XXXII:1/04.MedicalCollege Georgia
61References continued35. Etzel RA. Mycotoxins. JAMA 2002;287(4):36. Etzel RA, Balk SJ, Bearer C Fetal. Committee on Environmental Health American Academy of Pediatrics. Toxic effects of indoor molds. Pediatrics 1998;4:37. 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):38. CDC. Reportof the CDC Working Group on Pulmonary Hemorrhage and Hemosiderosis. Atlant,Georgia:CDCand Prevention 1999.39. 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):494-5.40. Kuhn DM, Ghannoun MA .Indoor mold, toxigenic fungi and Stachybotrys chartarum: Infectious disease perspective. Clinical Microbiology Reviews 2003;16(1):41. Bennett JW ,Klich M. Mycotoxins Clinical Microbiology Reviews 2003;16(3):42. Robbins CA, Swenson LJ, NealleyML et al Health effects of mycotoxins in indoor air :a critical review .Applied Occupational and Environmental Hygiene2000;15(10):43. 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
62References continued44. Bush RK, Portnoy J. The role of abatement of fungal allergens in .allergic diseases .JAllergy Clin Immunol 2001;107:S430-4045. Meklin T, Haugland RA, ReponenT, et al. Quantitative PCR analysis of house dust can reveal abnormal mold conditions. J EnvironMonit 2004;6(7):46. Kauffman HF, Van der Heide S. Exposure ,sensitization ,and mechanisms of fungus-induced asthma .Current Allergy and Asthma Reports 2003;3:47. Heibling A, Reimers A .Immunotherapy in fungal allergy. Current Allergy and Asthma Reports 2003;90:34-40.48. Eggleston P. Environmental control for fungal allergen exposure. Current Allergy and Asthma Reports 2003;3(5):426-9.49. EPA .Mold remediation in schools and commercial buildings.EPA 402-K-001 March 2001USEPA