MOLD by chenshu


									  Pediatric Environmental Health

Health Effects of Indoor Mold Exposure
  This educational module was produced by Rose Goldman, MD, MPH and Alan
  Woolf, MD, MPH for The University of Texas Health Science Center at San
Antonio (UTHSCSA) Environmental Medicine Education Program and South Texas
           Environmental Education and Research Program (STEER-San
   Administrative support was provided by the Association of Occupational and
       Environmental Clinics through funding to UTHSCSA by the Agency for
 Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and
                                 Human Services.
        Use of this program must include acknowledgement of the authors,
                        UTHSCSA and the funding support.
      For information about other educational modules contact the UTHSCSA
        STEER office, Mail Code 7796, 7703 Floyd Curl Drive, San Antonio,
                        Texas 78229-3900,(210)567-7407.
                      Talk Objectives

The participant will…
 Understand the pathogenesis of environment-related health problems
 Appreciate the taxonomy and regional variation of molds
 Appreciate the relationship between molds and other microbial
  overgrowth in a damp space
 Know how to assess the patient with health complaints related to
  living in a damp space
 Know how to assess the environment of a patient with damp space-
  related complaints
 Be able to cite aspects of mold clean-up and prevention
 Know how to access resources for further information

                                                             Photos courtesy: EPA
    Case: 14 month old with multiple respiratory
                illnesses? – Part 1

   2 previous episodes bronchiolitis – 12 visits to local
   2 episodes (1 hospitalization) for pneumonia
   Father has chronic cough of 2- months duration and
    complains of headaches. No fever but some
    greenish nasal discharge.
   Parents think that mold in their newly built home in
    this suburban community is the cause
   Here is the community…
Photo courtesy Alan Woolf, MD, MPH
    Pathogenesis of environmental & toxic injury

                                           Effective Dose
   Absorption                  Contact
   Distribution                             Biologic
   Metabolism                               Change
    Excretion                                               Clinical
                                          Repair            Disease
Building-Related Medical Illness

                 Medical Illness

    Specific Indoor Air         Non-specific „sick
     Quality Problems          building syndrome‟

 Allergic       Non-Allergic
What are some of the Major Indoor Air

   Respirable particles
   Oxides of nitrogen
   Carbon monoxide
   Volatile Organic Compounds (VOC’s)
   Radon and radon daughters
   Asbestos fibers
   Toxic dusts (lead)
   Environmental tobacco smoke
   Biologic Agents (eg mold, endotoxin) and indoor allergens
Typical Damp Environment-Related
         Health Complaints

  Headache
  Fatigue
  Light headedness
  Eye and nose irritation
  Cough
  Wheezing, exacerbation asthma
  Skin itching and rashes
        Risk Factors: Children

 Which children are susceptible to inhaled
 Why kids versus adults?
 Where besides the home would you look for
  environmental contaminants affecting
Risk Factors: childhood illness from poor indoor
    air quality and dampness-related effects

     » Closer to ground-level toxins
     » Higher minute ventilation
     » Pulmonary system
     » Immune system
     » Genetic
     » Prematurity?
     » Frequent wheezing, prior bronchiolitis
     » Chronic respiratory illness (e.g. cystic fibrosis)
     » Indoor air quality problems in school, preschool or daycare
                 Back to the case…
   This was a new home. There was no evidence for
    »   Dusty environment
    »   Carbon monoxide (detectors in place)
    »   Oxides of nitrogen
    »   Radon
    »   Water intrusion
    »   Asbestos
    »   Lead
   Parents denied any exposure to
    » Environmental tobacco smoke
    » Use of solvents or other VOCs
Biological Agents Growing on Damp Indoor Spaces

  Dust mite

                  Picture courtesy: John Martyny, PhD - EPA
Respiratory Illnesses + Damp Environments
•Asthma, wheezing, cough
and phlegm associated with
residing in damp or water-
damaged homes.
•Irritant related nasal, eye,
throat irritation
•Dampness also associated
with cockroach and mite
infestation, bacterial growth
(bacterial endotoxins),
                                Photo courtesy: EPA
   Institute Of Medicine: Damp Spaces

Sufficient Evidence - upper respiratory tract
symptoms, cough, wheeze, asthma in
sensitized person
Limited evidence - dyspnea, lower tract
illness in otherwise healthy person, asthma
  IOM Report: Damp Spaces

Inadequate or insufficient evidence:
  •Airflow obstruction, COPD
  •Acute idiopathic pulmonary hem. in infants
  •GI tract problems
  •Neuropsychiatric symptoms, fatigue
  •Reproductive effects
  •Rheumatologic and other immune diseases
                      Respirable Particles
   About 6000 liters of air
    exchange per day for an
   Smallest particles reach
   Some particles stimulate
    macrophage inflammatory
   Water soluble chemicals
    cause proximal irritation,
    less deposition distally

From chapter 16, Clinical Pulmonary Toxicology –author Lee S. Newman, in Sullivan JB and Krieger GR—
Clinical Environmental Health and Toxic
Pathogenesis of injury from molds &
          damp spaces
                  Mold &
                Damp Spaces

Allergy   Infection           Irritant   Mycotoxin
    Case: 14 month old with multiple respiratory
                illnesses? – Part 2

 2 previous episodes bronchiolitis – 12 visits
  to local MD
 2 episodes (1 hospitalization) for pneumonia
 Father has chronic cough of 2- months
  duration and complains of headaches
 What is in your differential diagnosis?
    Case: 14 month old with multiple respiratory
                illnesses? – Part 3

   Pediatrician’s preliminary diagnosis = asthma
  Pathogenesis of injury from molds &
            damp spaces
                      Mold &
                    Damp Spaces


Rhinitis ABPA   Asthma   rashes   Hypersensitivity
Allergic and Hypersensitivity Reactions

About 10% of the population has allergic antibodies to
fungal antigens, and 5% have clinical illness
Outdoor molds more abundant and important in airway
allergic disease
Allergic rhinitis (―hay fever‖) or asthma
   ―Atopic‖ individuals: mast cell degranulation, IgE
   antibodies (immediate hypersensitivity)
   Indoor common molds: Penicillium, Aspergillus
   Outdoor: Cladosporium, Alternaria (but can also come
   Uncommon Allergic and Hypersensitivity syndromes

Allergic bronchopulmonary aspergillosis
(ABPA)-growth of aspergillus in allergic
persons, or those with cystic fibrosis, with
airway damage from previous illnesses
Allergic bronchopulmonary mycosis
Allergic Fungal Sinusitis (AFS)-Aspergillus,
Specific criteria for ABPA and AFS
Exposure to ubiquitous organisms-no link to
specific exposures at home or school
         Hypersensitivity Pneumonitis

•Rare, exposures (usually occupational) to very high
concentrations of fungal (or other) proteins
•High levels of IgG proteins-detected in precipitin tests
or gel diffusion (BUT can have +IgG ab, no disease)
•Cell-mediated and humoral immune reactivity-delayed
intense local reactions
•Examples in humidifier and HVACs-thermophilic
Actinomyces (filamentous bacteria)
          Allergy Assessment
   Blood count, white cell count, % eosinophils
   Nasal eosinophils
   Immune competency: Ig levels, IgE
   Sweat test
   Chest x-ray
   RAST testing
   (Sensitivity testing)
   (Pulmonary function tests)
   (Provocative testing)

() reserved for older patients
      The family’s discovery…

 Attic had no fan and very small soffets
 It was a rainy, wet spring following the
  home’s construction
 The builder had used improperly cured
  ‘green’ plywood
Black mold in a newly constructed home

           Photo courtesy Alan Woolf, MD, MPH
Photo courtesy Alan Woolf, MD, MPH
                          molds are everywhere…

Photos courtesy: Rose Goldman, MD, MPH
Boston Globe – 06/14/03
Flooding from Katrina
     Types of indoor molds commonly associated
              with adverse health effects

   Alternaria – most common allergen
   Aspergillus (A. fumigatus, flavus, niger) – 175
    species, including 16 known human
    pathogens; filamentous, some strains
   Penicillium – 200 species, indoors, allergenic
    (hypersensitivity pneumonia, allergic
    alveolitis, keratitis, otomycosis, penicilliosis)
   Stachybotrys atra – thrives on cellulose (e.g.
    sheetrock, wallpaper, paper-backed gypsum,
    ceiling tiles, insulation), causes dermatitis,
    rhinitis, nose bleeds, cold symptoms, malaise
   Cladisporium – ubiquitous, breaks down
    cellulose, pectin, lignin, buoyant spores

                                                        Photos courtesy John Martyny, PhD - EPA
What about the father‟s complaints
of cough and headache?

What other information do you need
to know about his illness?
Differential diagnosis considerations of
     cough & headache in an adult

   Pneumonia               Migraine
   Chronic Bronchitis      Tension Headache
   Cough-Equivalent        Dental abscess
    Asthma                  Sinusitis
   Gastroesophageal
Pathogenesis of injury from molds &
          damp spaces
                   Mold &
                 Damp Spaces

Allergy    Infection           Irritant   Mycotoxin

                   Case Outcomes
   Parents relocated to grandparents’ home in the next town
   No further health complaints: child or father
   Family successfully sued builder for remediation
   This outcome does not prove that mold caused the health
   For example, airborne and dust-laden endotoxin from
    bacteria,volatile organic compounds associated with
    microbial overgrowth, dust mite or cockroach antigens, or
    airborne particulates might also have played causative
Pathogenesis of injury from molds &
          damp spaces
               Mold &
             Damp Spaces

                    Irritant: direct or
                     VOC mediated

             Eye, nose,
               throat              Cough, wheeze
Pathogenesis of injury from molds &
          damp spaces
               Mold &
             Damp Spaces


            pulmonary             Pneumonia
              Examples of Mycotoxins

                                         Aflatoxin
                                         Cyclochloritine
                                         Ethanol
                                         Griseofulvin
                                         Ipomeamarone
                                         Luteoskyrin
                                         Ochratoxin
                                         Sporidesmin
                                         Sterigmatocystin
Photo courtesy: Terry Brennan - EPA      Tetracycline
     Poisoning related to mycotoxins
 Toxigenic species do not always produce toxins
 Mycotoxins: usually large, non-volatile molecules
  that do not ‘off-gas’ or pass through walls
 Ingestion of moldy foods (e.g. aflatoxin in grains
  produces hepatitis & hepatocarcinoma)
 Stachybotrys species produce trichothecenes
 Stachybotrys-associated infantile pulmonary

   Greenish black,
    saprophytic, grows well on
   Produces spores in a
    slimy, mucilaginous mass
   Some species produce
   Controversy over 10 cases
    infantile pulmonary
    hemorrhage in Cleveland,
                                 Photo courtesy EPA
        Stachybotrys chartarum
        Kuhn DM, Ghannoum MA. Clin Microbiol Rev 2003; 16:144-72

•Is there illness found with building associated
mycotoxins produced by Stachybotrys , or “toxic mold”?
•Acute pulmonary hemorrhage in infants in room with
•For toxicity: need high exposure - What is a toxic dose?
Could it occur in a typical indoor environments
•current human studies “uniformly suffer from
significant methodological flaws, making their findings
inconclusive…have not found supportive evidence for
serious illness due to Stachybotrys exposure...”
Pathogenesis of infection from molds

                                  Mold &
                                Damp Spaces


  Skin & nail       Immuno
   infections     Compromised

infection   Sinusitis ABPA pneumonia
                Fungal Pathogens

Fungal Pathogens - regional,
often do not grow indoors
   •Candida - ubiquitous
   •Cryptococcus - associated
   with bird droppings
   •Histoplasma - (bats) Ohio
   •Coccidioides -
   Southwestern U.S.
           Visual Assessment - Environment

•Interior materials: wet carpet, insulation
•Building materials: wet wood, wallboard,
ceiling tiles
•Furnishings: damp fleecy furnishings
•Heating, Ventilation, Air Conditioning
(HVAC): condensate pans, moist dirty          Photo courtesy Terry Brennan - EPA

•Pipes, Drainage: clogged drains, wet traps,
leaking water pipes, wet pipe wrappings
•Ventilation: blocked soffets & vents, no fans
                                                       Photo courtesy John Martyny, PhD - EPA
   Assessment of possible mold-related illness

•Biological assessment:
characterize signs and
symptoms – confirmatory
testing when indicated
visual inspection
air samples (spore count,                  Photos courtesy
                                           EPA website
               Indoor airborne fungi levels

• Indoor air levels are a reflection of
outdoor levels (estimated at 40%-
80% of outdoor levels) with similar
rank order species of fungi.
• Concentrations of fungi in samples
not exposed directly to indoor air
may not indicate inhalation risk                             Photo courtesy EPA
• Estimated that 70% of homes have
some mold growing behind walls.
Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309
         Examples of seasonal total mold counts in the U.S.

Location                   March–June: spores/m3 Sept–Dec: spores/m3

St. Louis                  395–24,500                            5266–68,855

Las Vegas                  8–673                                 15–186

Albany, NY                 9–1534                                1075–18,005

Santa Barbara,CA 544–33,090                                      767–555,833
Data from the National Allergy Bureau, American Academy of Allergy, Asthma
and Immunology. Pollen and mold counts. Available at:

Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309
Photo: courtesy Rose Goldman, M.D.
              Limitations of Testing
   Airborne spores are usually 4-
    100 microns diameter
   Spore counts do not
    necessarily predict symptoms
   Not all spores are equally
   Spore counts may fluctuate
    daily, seasonally
   This is not an exact science!

                               Photos courtesy John Martyny, PhD – EPA website
                 Management & Prevention

                                         Photo by: Mike Ahlers, CNN
Photo: FEMA, Naumann

            What do you see in these pictures?
            What is possibly the composition of the slime?
            What good & bad practices do you see in the clean-up?
                 Hazard Reduction
   Environment: Prevent water
    intrusion, all reused materials
    dried and visibly mold-free
   Clean-Up: Proper PPE, Mold
    disinfectant (hypochlorites) or
    disposal – EPA recommends                                               N-95 respirator
    hiring a professional for mold     Above photo courtesy Chin Yang
    growths > 10 square feet in size
   Monitoring Post-occupancy:
    De-humidification < 60%
    relative humidity

                                           3 photos courtesy Terry Brennan & EPA website

   Mold-related exposures: over-diagnosed, costly, preventable
   Damp spaces: cause poor health (mold only one of many concerns)
   Children’s differences: size, physiology, development, behaviors
   Mechanisms of mold injury:
    »   Irritant
    »   Allergy
    »   Infectious
    »   Toxic
   Common clinical issues:
    » Mold-related illness:
         – diagnosis & medical management
    » Safe environmental clean-up
    » Prevention
      Resources: Mold-Related Illness

 Clinical Resources: Occupational &
  Environmental Clinics; Pediatric Environmental
  Health Subspecialty Units; AOEC
 Local & State Health Departments
 ATSDR & Regional EPA

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