damp indoor space and your patient : what’s mold got to do with it?

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Damp Indoor Space and Your PatientDamp Indoor Space and Your Patient : :What’s Mold Got To Do With It?What’s Mold Got To Do With It?

Carl Baum, MD, FAAP, FACMTCarl Baum, MD, FAAP, FACMTAssociate Professor of PediatricsAssociate Professor of Pediatrics

Yale University School of MedicineYale University School of Medicine

Director, Center for Children’s Environmental Director, Center for Children’s Environmental ToxicologyToxicology

Yale-New Haven Children’s HospitalYale-New Haven Children’s Hospital

Marian L Heyman, MT (ASCP), MPHMarian L Heyman, MT (ASCP), MPHEpidemiologist/Industrial HygienistEpidemiologist/Industrial Hygienist

Coordinator, Indoor Environmental Quality PrgCoordinator, Indoor Environmental Quality Prg

Environmental Epidemiology & Occupational Environmental Epidemiology & Occupational Health ProgramHealth Program

Connecticut Dept. of Public HealthConnecticut Dept. of Public Health

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CaseCase

• 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”I’m allergic to mold”– Petitioned last year to change schoolsPetitioned last year to change schools– Re-entered old school for a rehearsalRe-entered old school for a rehearsal– Became acutely short of breathBecame acutely short of breath

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CaseCase

• 15-year-old girl15-year-old girl

• Increased WOBIncreased WOB

• Physical Exam:Physical Exam:– Anxious, hyperventilatingAnxious, hyperventilating– T = 37 C P = 90 RR = 45 BP = 130/70T = 37 C P = 90 RR = 45 BP = 130/70– Room air oxygen saturation = 100%Room air oxygen saturation = 100%– Chest: CTA without wheeze; good aerationChest: CTA without wheeze; good aeration

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CaseCase

• 15-year-old girl15-year-old girl

• Increased WOBIncreased WOB

• Assessment?Assessment?

• Plan?Plan?

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Mycology BasicsMycology BasicsFungi = yeasts and moldFungi = yeasts and mold

YeastsYeasts•UnicellularUnicellular

•Round, globoseRound, globose

•Most reproduce by Most reproduce by buddingbudding

MoldMold•Multicellular, filamentousMulticellular, filamentous

•Filaments - hyphae Filaments - hyphae

•““mat” of hyphae = mat” of hyphae = myceliummycelium

•Reproduce from fruiting Reproduce from fruiting body via conidia (spores) body via conidia (spores) which can become airbornewhich can become airborne

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Fast Facts About FungiFast Facts About Fungi

• Lack chlorophyll Lack 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 Ubiquitous in nearly allnearly all environments environments

““But before you move to Antarctica, remember But before you move to Antarctica, remember that mold spores also grow indoors, making it a that mold spores also grow indoors, making it a year-round problem.”year-round problem.”

Asthma & Allergy Foundation of AmericaAsthma & Allergy Foundation of America

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Fast Facts About FungiFast Facts About Fungi

• Fungal cell walls containFungal cell walls contain 1-3-ß-d-Glucan, which can cause 1-3-ß-d-Glucan, which can cause inflammation.inflammation.

• Spores & mycelium contain allergens; most Spores & mycelium contain allergens; most have not been chemically characterizedhave not been chemically characterized

• Many of the known fungal allergens are Many of the known fungal allergens are proteins found in fairly high concentrations in proteins found in fairly high concentrations in the spores.the spores.

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Fast Facts About FungiFast Facts About Fungi

• Fungal spores size range: 1 to Fungal spores size range: 1 to 50 ųm. 50 ųm.

• Humidity can affect sizeHumidity can affect size

• Spores < 10 ųm can be Spores < 10 ųm can be deposited in alveoli; smaller deposited in alveoli; smaller can be swallowedcan be swallowed

• Lower airway deposition for Lower airway deposition for 5 ųm particles is six times 5 ųm particles is six times higher in newborns than in higher in newborns than in adults (Phalen and Oldham adults (Phalen and Oldham 2001)2001)

• The spores in some species The spores in some species contain low molecular weight contain low molecular weight chemicals that are cytotoxic chemicals that are cytotoxic [mycotoxins][mycotoxins]

Alternaria sporesAlternaria spores

Cladosporium sporesCladosporium sporesPenicillium sp. Stachybotris spores

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Medically Important FungiMedically Important Fungi• Most belong to Most belong to

phylum phylum DeuteromycotaDeuteromycota, or , or Fungi ImperfectiFungi Imperfecti

Aspergillus fumigatusAspergillus fumigatus

Disease Ranges:Disease Ranges:

Superficial mycoses with Superficial mycoses with no pathological changes no pathological changes to systemic mycoses- to systemic mycoses- invasive, lethalinvasive, lethal

Lung Tissue: Lung Tissue: Fungal Fungal Pneumonia- Pneumonia- Aspergillus Aspergillus fumigatusfumigatus

Note septate Note septate hyphae, hyphae, dichotomous dichotomous branchingbranching

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Indoor Environmental FungiIndoor Environmental Fungi• Opportunistic FungiOpportunistic Fungi

– Almost exclusively affect Almost exclusively affect debilitated patientdebilitated patient

– Allergy in pts w/ Allergy in pts w/ underlying respiratory underlying respiratory conditions i.e., asthma or conditions i.e., asthma or cystic fibrosiscystic fibrosis

– Opportunistic infections Opportunistic infections in immunocompromised in immunocompromised ptspts

• Enter buildings on our Enter buildings on our clothes, shoes, pets, clothes, shoes, pets, windows, doors, windows, doors, mechanical ventilation mechanical ventilation systemssystems

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Mold Is In Every Home In The Mold Is In Every Home In The USAUSA

Just because mold is found in a building, it Just because mold is found in a building, it doesn’t mean everyone will be exposed or doesn’t mean everyone will be exposed or become symptomatic. In order to be exposed, become symptomatic. In order to be exposed, people must either: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)

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What are the Reported Health What are the Reported Health Effects?Effects?

• AllergicAllergic

• InfectiousInfectious

• ToxicToxic

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AllergicAllergic

• 10% of population has antibodies to fungal 10% of population has antibodies to fungal antigensantigens

• 5% expected to show clinical illness5% expected to show clinical illness– allergic asthmaallergic asthma– allergic rhinitis (“hay fever”)allergic rhinitis (“hay fever”)

• Hypersensitivity pneumonitisHypersensitivity pneumonitis– more serious but raremore serious but rare

• Outdoor molds more abundantOutdoor molds more abundant

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InfectiousInfectious

• Benign tineaBenign tinea– ……pedis, cruris, corporus, onychomycosispedis, cruris, corporus, onychomycosis

• PathogenicPathogenic– BlastomycesBlastomyces– CoccidioidesCoccidioides– CryptococcusCryptococcus– HistoplasmaHistoplasma

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ToxicToxic

• Secondary metabolites (mycotoxins)Secondary metabolites (mycotoxins)– not required for survival of fungusnot required for survival of fungus

• Clinical use Clinical use – PCN, CSAPCN, CSA

• InhalationInhalation– blamed for numerous non-specific blamed for numerous non-specific

symptomssymptoms

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MMWRMMWR January 17, 1997 / 46(02);33-35January 17, 1997 / 46(02);33-35

Update: Pulmonary Hemorrhage/Hemosiderosis Among Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants -- Cleveland, Ohio, 1993-1996Infants -- Cleveland, Ohio, 1993-1996

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 1994. 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.

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Acute Idiopathic Pulmonary Acute Idiopathic Pulmonary HemorrhageHemorrhage

• 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 CDC case-control study identified 2 associationsassociations

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Case-control StudyCase-control Study

• Major associationsMajor associations– Major water damage in previous 6 monthsMajor water damage in previous 6 months– Increased levels of Increased levels of Stachybotrys chartarumStachybotrys chartarum

• HypothesisHypothesis– AIPH AIPH may may be caused by mycotoxinsbe caused by mycotoxins

• ““further research is needed to determine further research is needed to determine causal[ity]”causal[ity]”

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Case-control StudyCase-control Study

• Findings cited in Findings cited in – Environmental health guidelinesEnvironmental health guidelines– Congressional testimonyCongressional testimony– Popular mediaPopular media

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August 12, 2001August 12, 2001

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““Haunted by Mold”Haunted by Mold”

• Melinda BallardMelinda Ballard• Dripping Springs, TXDripping Springs, TX

• “…“…she pulls out two portable respirator masks. she pulls out two portable respirator masks. “These won’t screen out all the mycotoxins,” she “These won’t screen out all the mycotoxins,” she warns as she tosses one to me. “That’s the warns as she tosses one to me. “That’s the dangerous stuff, so we’ll only stay a few minutes.”dangerous stuff, so we’ll only stay a few minutes.”

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““Haunted by Mold”Haunted by Mold”

• 4-year-old son became ill4-year-old son became ill– ““coughing up blood”coughing up blood”– ““equilibrium…completely shot”equilibrium…completely shot”– ““very bad stomach problems”very bad stomach problems”

• vomiting, diarrheavomiting, diarrhea

– “…“…it just spanned the whole globe in terms it just spanned the whole globe in terms of symptoms.”of symptoms.”

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Arizona Republic, 1/11/02Arizona Republic, 1/11/02

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““Mold Kids”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 Many homebound or transferred to other

schools because of “mold-related symptoms”schools because of “mold-related symptoms”– ““respiratory distress”respiratory distress”– “…“…still suffers from a sinus infection as a still suffers from a sinus infection as a

result of her time at [Amity] Junior High.”result of her time at [Amity] Junior High.”

Orange Bulletin, 4/14/04Orange Bulletin, 4/14/04

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Review of AIPH InvestigationReview of AIPH Investigation

• Reported OR of 9.8 for change of 10 CFU/mReported OR of 9.8 for change of 10 CFU/m33 – Statistically unstable and potentially inflatedStatistically unstable and potentially inflated– OR =1.5?OR =1.5?

• SamplingSampling– Not blinded (2x in case homes) and aggressiveNot blinded (2x in case homes) and aggressive

• Water-damage classificationWater-damage classification– Little difference in airborne Little difference in airborne S. chartarum S. chartarum levelslevels– Unrecognized correlate of water damage?Unrecognized correlate of water damage?

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Review of AIPH InvestigationReview of AIPH Investigation

• Evidence not of sufficient quality to Evidence not of sufficient quality to support an association between AIPH support an association between AIPH and and S. chartarumS. chartarum

• Clusters of AIPH have Clusters of AIPH have notnot been been reported in other flood-prone areas reported in other flood-prone areas where where S. chartarum S. chartarum and other toxigenic and other toxigenic fungi might be favoredfungi might be favored

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Evidence-based MedicineEvidence-based Medicine

• ACOEM (2002)ACOEM (2002)

• IOM (2004)IOM (2004)

• WHO (2009)WHO (2009)

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ACOEMACOEM

• 2002 evidence-based statement 2002 evidence-based statement

– Current scientific evidence does Current scientific evidence does notnot support causal relationship between support causal relationship between inhaled mycotoxins and adverse inhaled mycotoxins and adverse health effectshealth effects

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Evidence-based MedicineEvidence-based Medicine

• CDC requestCDC request

– Institute of Medicine (IOM)Institute of Medicine (IOM)

• Committee on Damp Indoor Spaces and HealthCommittee on Damp Indoor Spaces and Health

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IOMIOM

• 2004 Report 2004 Report – 341 pages341 pages

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Damp Indoor Spaces:Damp Indoor Spaces:Categories of EvidenceCategories of Evidence

• Sufficient evidence of a causal Sufficient evidence of a causal relationshiprelationship

• Sufficient evidence of an associationSufficient evidence of an association

• Limited or suggestive evidence of an Limited or suggestive evidence of an associationassociation

• Inadequate or insufficient evidence to Inadequate or insufficient evidence to determine whether an association existsdetermine whether an association exists

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Health Outcomes vs MoldHealth Outcomes vs Mold

• Sufficient evidence of a causal Sufficient evidence of a causal relationshiprelationship

• Sufficient evidence of an associationSufficient evidence of an association

• Limited or suggestive evidence of an Limited or suggestive evidence of an associationassociation

• Inadequate or insufficient evidence to Inadequate or insufficient evidence to determine whether an association existsdetermine whether an association exists

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Health Outcomes vs MoldHealth Outcomes vs Mold

• SufficientSufficient evidence of a evidence of a causalcausal relationship:relationship:

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Health Outcomes vs MoldHealth Outcomes vs Mold

• SufficientSufficient evidence of a evidence of a causalcausal relationship:relationship:

No outcomes met definitionNo outcomes met definition

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Health Outcomes vs MoldHealth Outcomes vs Mold

• Sufficient evidence of a causal Sufficient evidence of a causal relationshiprelationship

• Sufficient evidence of an associationSufficient evidence of an association

• Limited or suggestive evidence of an Limited or suggestive evidence of an associationassociation

• Inadequate or insufficient evidence to Inadequate or insufficient evidence to determine whether an association existsdetermine whether an association exists

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Health Outcomes vs MoldHealth Outcomes vs Mold

• SufficientSufficient evidence of an evidence of an association:association:

Upper respiratory tract symptomsUpper respiratory tract symptoms

Asthma in sensitized asthmaticsAsthma in sensitized asthmatics

Hypersensitivity pneumonitis (susceptible)Hypersensitivity pneumonitis (susceptible)

WheezeWheeze

CoughCough

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Health Outcomes vs MoldHealth Outcomes vs Mold

• Sufficient evidence of a causal Sufficient evidence of a causal relationshiprelationship

• Sufficient evidence of an associationSufficient evidence of an association

• Limited or suggestive evidence of an Limited or suggestive evidence of an associationassociation

• Inadequate or insufficient evidence to Inadequate or insufficient evidence to determine whether an association existsdetermine whether an association exists

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Health Outcomes vs MoldHealth Outcomes vs Mold

• LimitedLimited or or suggestivesuggestive evidence of evidence of

an an association:association:

Lower respiratory illness in otherwise-Lower respiratory illness in otherwise-healthy childrenhealthy children

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Health Outcomes vs MoldHealth Outcomes vs Mold

• Sufficient evidence of a causal Sufficient evidence of a causal relationshiprelationship

• Sufficient evidence of an associationSufficient evidence of an association

• Limited or suggestive evidence of an Limited or suggestive evidence of an associationassociation

• Inadequate or insufficient evidence to Inadequate or insufficient evidence to determine whether an association existsdetermine whether an association exists

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Health Outcomes vs MoldHealth Outcomes vs Mold

• InadequateInadequate or or insufficientinsufficient evidence to evidence to determine whether an determine whether an associationassociation exists: 1/3exists: 1/3

DyspneaDyspneaAirflow obstruction (otherwise healthy)Airflow obstruction (otherwise healthy)Mucous membrane irritation syndromeMucous membrane irritation syndromeChronic obstructive pulmonary diseaseChronic obstructive pulmonary diseaseInhalational fevers (non-occupational)Inhalational fevers (non-occupational)

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Health Outcomes vs MoldHealth Outcomes vs Mold

• InadequateInadequate or or insufficientinsufficient evidence to evidence to determine whether an determine whether an associationassociation exists: 2/3exists: 2/3

Lower respiratory illness (healthy adults)Lower respiratory illness (healthy adults)Rheumatologic / other immune diseaseRheumatologic / other immune diseaseAcute idiopathic pulmonary hemorrhageAcute idiopathic pulmonary hemorrhageSkin symptomsSkin symptomsAsthma developmentAsthma development

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Health Outcomes vs MoldHealth Outcomes vs Mold

• InadequateInadequate or or insufficientinsufficient evidence to evidence to determine whether an determine whether an associationassociation exists: 3/3exists: 3/3

Gastrointestinal tract problemsGastrointestinal tract problemsFatigueFatigueNeuropsychiatric symptomsNeuropsychiatric symptomsCancerCancerReproductive effectsReproductive effects

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““Toxic Mold”Toxic Mold”

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Indoor MoldIndoor Mold

• Molds blamed for variety of ailments Molds blamed for variety of ailments and disabilitiesand disabilities

• Subject of litigationSubject of litigation– Ballard case: $32 millionBallard case: $32 million

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DPH MessageDPH Message

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

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Don’t Test!Don’t Test!• Find the water source and stop the Find the water source and stop the

leakingleaking• Discard water-damaged porous Discard water-damaged porous

materials materials • Clean non-porous surfaces with 10% Clean non-porous surfaces with 10%

bleach (1 part bleach + 9 parts water) – bleach (1 part bleach + 9 parts water) – allow it to dry naturallyallow it to dry naturally

• Never mix ammonia with bleachNever mix ammonia with bleach

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Don’t Test!Don’t Test!• Ventilate – open windows/doors, and/or Ventilate – open windows/doors, and/or

turn on air handling systemsturn on air handling systems• Keep relative humidity below 60% at all Keep relative humidity below 60% at all

times times – Use a dehumidifier in the basement, empty Use a dehumidifier in the basement, empty

whenever neededwhenever needed– Buy a hygrometer to measure relative Buy a hygrometer to measure relative

humidity to be sure dehumidifier is doing humidity to be sure dehumidifier is doing it’s job.it’s job.

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Why Are There No Standards Why Are There No Standards For Indoor Mold?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

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Environmental Air SamplingEnvironmental Air Sampling

• Generally, Generally, waste of waste of time & time & resourcesresources

• Will Will always always show show mold!mold!

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What About Indoor vs. What About Indoor vs. Outdoor Spore Counts?Outdoor Spore Counts?

• Unless there is a specific indoor source for Unless there is a specific indoor source for specific microbes, indoor conc. will always be specific microbes, indoor conc. will always be lower than outdoorslower than outdoors

• Outdoor bioaerosols come indoors at rates Outdoor bioaerosols come indoors at rates dependent upon nature of ventilation to interiordependent upon nature of ventilation to interior

• Naturally ventilated bldgs will have more orgs. Naturally ventilated bldgs will have more orgs. from outdoor sources that tighter bldgsfrom outdoor sources that tighter bldgs

• The I/O ratio is a function of ventilation, The I/O ratio is a function of ventilation, infiltration/exfiltration & other things infiltration/exfiltration & other things not related not related to indoor mold growthto indoor mold growth

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Real Data From a HomeReal Data From a HomeSpore trap results showing normal daily fluctuation

What does it mean?

TimeIndoors,Bedroom

Outdoors, Front

9:45 AM 895 71:00 PM 12 1013:30 PM 21 120

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What Can the Provider Do?What Can the Provider Do?

• Take an environmental historyTake an environmental history– Typical questionsTypical 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 fromPrimers available from• EPAEPA• National Environmental Education FoundationNational Environmental Education Foundation

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What Can the Provider Do?What Can the Provider Do?

• Point out normal exam findingsPoint out normal exam findings

• Explain the evidenceExplain the evidence– lack of causalitylack of causality

• Reassure parents and patientsReassure parents and patients

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Putting Mold into PerspectivePutting Mold into Perspective

Etiology Deaths Source Year

Poisoning 1,535 AAPCC 2008

Radon 20,000 EPA 2010

Motor Vehicle Crashes 34,000 NHTSA 2009

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SummarySummary

Mold Mold • UbiquitousUbiquitous• Requires waterRequires water• No evidence for No evidence for causalcausal relationship with relationship with

human illnesshuman illness• Some evidence for Some evidence for associationassociation with with

selected illnessesselected illnesses

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Take-home MessageTake-home Message

• MedicalMedical– Most fungi NOT pathogenic to healthy Most fungi NOT pathogenic to healthy

humanshumans

• EnvironmentalEnvironmental– Don’t ask for air samplingDon’t ask for air sampling– Source reduction is most importantSource reduction is most important– Call DPH w/ further concerns, i.e., Call DPH w/ further concerns, i.e.,

environmental assessmentsenvironmental assessments

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E-ResourcesE-Resources

• CT Department of Public Health CT Department of Public Health http://www.ct.gov/dph/moldhttp://www.ct.gov/dph/mold

• Environmental Protection Agency Environmental Protection Agency http://www.epa.gov/mold/ http://www.epa.gov/mold/

• Health Canada Health Canada http://www.hc-sc.gc.ca/hl-vs/iyh-vsv/environ/air-eng.phphttp://www.hc-sc.gc.ca/hl-vs/iyh-vsv/environ/air-eng.php

• Canada Mortgage and Housing Corp’s Canada Mortgage and Housing Corp’s About About Your HouseYour House Series. Series.http://www.cmhc-schl.gc.ca/en/co/co_001.cfmhttp://www.cmhc-schl.gc.ca/en/co/co_001.cfm

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E-ResourcesE-Resources• Guidance for clinicians on the recognition and management of health effects

related to mold exposure and moisture indoors. UCHC.• http://oehc.uchc.edu/clinser/MOLD%20GUIDE.pdf

• Environmental and Occupational History. Chapter 3. In: Recognition And Management of Pesticide Poisonings. U.S Environmental Protection Agency. EPA 375-R-98-003. March 1999.

http://www.epa.gov/opp00001/safety/healthcare/handbook/handbook.htm

• National Environmental Education Foundation • Pediatric Environmental History Initiative:

http://www.neefusa.org/health/PEHI/index.htm • Pediatric Environmental History Primer

http://www.neefusa.org/pdf/primer.pdf• Pediatric Environmental History Forms

http://www.neefusa.org/pdf/primer.pdf

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Contact Us!Contact Us!

Carl Baum, MD Marian L. Heyman, MT, MPH

203.641.TOXI (8694) 860.509.7742

carl.baum@yale.edu marian.heyman@ct.gov