Respiratory morbidity among children following renovation of a water-damaged school

Effect of prenatal and postnatal exposure to home renovation on the risk of common cold in preschool children

Common cold is usually considered to be associated with outdoor climate, but the evidence linking with indoor environmental factors is lacking. The role of indoor renovations during which critical timing window on childhood common cold remains unclear. Therefore, we investigated the effect of exposure to new furniture and/or redecoration during prenatal and postnatal periods on the occurrence and duration of common cold in preschool children. We conducted a retrospective cohort study of 39 782 children aged 3-6 years in seven cities of China. The occurrence and duration of common cold in children, and their lifetime exposures to indoor new furniture and redecoration (including pregnancy, the first year of life, and after one year old) were assessed using a questionnaire administered by the parents. Associations between high frequency (>5 colds) and long duration (≥2 weeks per cold) of common cold during past 12 months and exposure to indoor new furniture/redecoration were examined by logistic regression models in terms of odds ratio (OR) and 95% confidence interval (CI). We found that the prevalence of high frequency and long duration of common cold in preschool children in China were, respectively, 9.2% and 11.9%. Frequent common cold was significantly associated with exposure to indoor new furniture/redecoration during pregnancy, first year, and after 1 year old, respectively, with the ORs (95% CI) = 1.25 (1.12-1.39), 1.11 (1.00-1.25), and 1.09 (1.01-1.18). Furthermore, childhood long duration per cold was associated with exposure to indoor new furniture/redecoration during pregnancy with OR (95% CI) of 1.14 (1.03-1.25) but not with postnatal exposure. We identified that prenatal exposure to home renovation was more critical than postnatal exposure for an increased risk of high frequency and long duration of common cold. Sensitivity analysis showed that the association between prenatal exposure to indoor renovations and the risk of childhood common cold was consistent and robust, and the associations were modified by some personal and indoor environmental factors. Our findings indicated that prenatal and postnatal exposure to home renovation played an important role in the risk of childhood common cold, supporting the hypothesis of "fetal origin of childhood infection."

Municipal challenges in managing a building with noted health symptoms

Purpose

This study aims to present property management challenges that municipalities have encountered regarding a public building with noted building-related symptoms. The study goes on to provide reasons for the failure of attempts to manage the symptoms and discusses the current challenges concerning the process.

Design/methodology/approach

A participatory case study was used as the research methodology to identify the current challenges concerning a municipal approach to managing the building-related symptoms in a case-study building. The researchers scrutinised the history of the health symptom management process and attended the project planning meetings focused on the investigation of the condition of the building.

Findings

Multiple challenges concerning maintenance and omitted or postponed repair actions, as well as vagueness in the management process were found. In addition to this, it was noted that the complexity of the initial design of the building and vandalism have resulted in challenges for the maintenance and moisture performance of the building structures. According to the study, more orderliness and a more systematic process is needed when managing a municipal property.

Practical implications

The identified property management challenges may be of practical value for the facility managers and the property owners, especially when managing the building-related symptoms and a damaged building.

Originality/value

This study highlights the importance of having an in-depth understanding of condition assessments as well as proper maintenance and timely repairs for the successful management of the building-related symptoms in a municipal building. This is a pilot project in a larger project of management of building refurbishment.

Does dampness and mold in schools affect health? Results of a meta-analysis

This paper provides meta-analyses of the published findings relating the respiratory health of occupants of schools with visible dampness, water damage, visible mold, and/or mold odor. Random effects models were used to develop central estimates and confidence limits for the associations of respiratory health effects with school dampness and mold. Eleven studies, all with cross-sectional designs, were included in the meta-analyses; however, analyses for some health outcomes were based on as few as four studies. Analyses were performed using data from adults and children combined, using only data from children, and using data from adults and children after excluding two studies. The central estimates of odds ratios from the meta-analyses were consistently above unity. The evidence of adverse health effects was strongest for cough and wheeze, which had confidence limits excluding unity in some or all analyses. The odds ratios of 1.32 for cough and 1.68 for wheeze suggest moderate increases in health risk. Studies not included in the meta-analyses provide additional evidence that dampness and mold in schools are associated with adverse health outcomes. These meta-analyses and the published literature not included in the meta-analyses suggest that dampness and mold in schools are associated with adverse respiratory health effects.

Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma

BACKGROUND

Dampness and mould in buildings have been associated with adverse respiratory symptoms, asthma and respiratory infections of inhabitants. Moisture damage is a very common problem in private houses, workplaces and public buildings such as schools.

OBJECTIVES

To determine the effectiveness of repairing buildings damaged by dampness and mould in order to reduce or prevent respiratory tract symptoms, infections and symptoms of asthma.

SEARCH METHODS

We searched CENTRAL (2014, Issue 10), MEDLINE (1951 to November week 1, 2014), EMBASE (1974 to November 2014), CINAHL (1982 to November 2014), Science Citation Index (1973 to November 2014), Biosis Previews (1989 to June 2011), NIOSHTIC (1930 to March 2014) and CISDOC (1974 to March 2014).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs (cRCTs), interrupted time series studies and controlled before-after (CBA) studies of the effects of remediating dampness and mould in a building on respiratory symptoms, infections and asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the included studies.

MAIN RESULTS

We included 12 studies (8028 participants): two RCTs (294 participants), one cRCT (4407 participants) and nine CBA studies (3327 participants). The interventions varied from thorough renovation to cleaning only.Repairing houses decreased asthma-related symptoms in adults (among others, wheezing (odds ratio (OR) 0.64; 95% confidence interval (CI) 0.55 to 0.75) and respiratory infections (among others, rhinitis (OR 0.57; 95% CI 0.49 to 0.66), two studies, moderate-quality evidence). For children, we did not find a difference between repaired houses and receiving information only, in the number of asthma days or emergency department visits because of asthma (one study, moderate-quality evidence).One CBA study showed very low-quality evidence that after repairing a mould-damaged office building, asthma-related and other respiratory symptoms decreased. In another CBA study, there was no difference in symptoms between full or partial repair of houses.For children in schools, the evidence of an effect of mould remediation on respiratory symptoms was inconsistent and out of many symptom measures only respiratory infections might have decreased after the intervention. For staff in schools, there was very low-quality evidence that asthma-related and other respiratory symptoms in mould-damaged schools were similar to those of staff in non-damaged schools, both before and after intervention.

AUTHORS' CONCLUSIONS

We found moderate to very low-quality evidence that repairing mould-damaged houses and offices decreases asthma-related symptoms and respiratory infections compared to no intervention in adults. There is very low-quality evidence that although repairing schools did not significantly change respiratory symptoms in staff, pupils' visits to physicians due to a common cold were less frequent after remediation of the school. Better research, preferably with a cRCT design and with more validated outcome measures, is needed.

Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma (Review)

BACKGROUND

Dampness and mould in buildings have been associated with adverse respiratory symptoms, asthma and respiratory infections of inhabitants. Moisture damage is a very common problem in private houses, workplaces and public buildings such as schools.

OBJECTIVES

To determine the effectiveness of remediating buildings damaged by dampness and mould in order to reduce or prevent respiratory tract symptoms, infections and symptoms of asthma.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1951 to June week 1, 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), Science Citation Index (1973 to June 2011), Biosis Previews (1989 to June 2011), NIOSHTIC (1930 to November 2010) and CISDOC (1974 to November 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs (cRCTs), interrupted time series studies and controlled before-after (CBA) studies of the effects of remediating dampness and mould in a building on respiratory symptoms, infections and asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the included studies.

MAIN RESULTS

We included eight studies (6538 participants); two RCTs (294 participants), one cRCT (4407 participants) and five CBA studies (1837 participants). The interventions varied from thorough renovation to cleaning only. We found moderate-quality evidence in adults that repairing houses decreased asthma-related symptoms (among others, wheezing (odds ratio (OR) 0.64; 95% confidence interval (CI) 0.55 to 0.75) and respiratory infections (among others, rhinitis (OR 0.57; 95% CI 0.49 to 0.66)). For children, we found moderate-quality evidence that the number of acute care visits (among others mean difference (MD) -0.45; 95% CI -0.76 to -0.14)) decreased in the group receiving thorough remediation. One CBA study showed very low-quality evidence that after repairing a mould-damaged office building, asthma-related and other respiratory symptoms decreased. For children and staff in schools, there was very low-quality evidence that asthma-related and other respiratory symptoms in mould-damaged schools were similar to those of children and staff in non-damaged schools, both before and after intervention. For children, respiratory infections might have decreased after the intervention.

AUTHORS' CONCLUSIONS

We found moderate to very low-quality evidence that repairing mould-damaged houses and offices decreases asthma-related symptoms and respiratory infections compared to no intervention in adults. There is very low-quality evidence that although repairing schools did not significantly change respiratory symptoms in staff or children, pupils' visits to physicians due to a common cold were less frequent after remediation of the school. Better research, preferably with a cRCT design and with more validated outcome measures, is needed.

Dampness and mould in schools and respiratory symptoms in children: the HITEA study

BACKGROUND

The adverse respiratory health effects of dampness and mould in the home have been extensively reported, but few studies have evaluated the health effects of such exposures in schools.

OBJECTIVES

To assess the associations between dampness and mould in school buildings and respiratory symptoms among 6-12-year-old pupils in three European countries with different climates.

METHODS

Based on information from self-reports and observations, we selected 29 primary schools with and 27 without moisture damage in Spain, the Netherlands and Finland. Information on respiratory symptoms and potential determinants was obtained using a parent-administered questionnaire among 6-12-year-old pupils. Country-specific associations between moisture damage and respiratory symptoms were evaluated using multivariable multilevel mixed effects logistic regression analysis.

RESULTS

Data from 9271 children were obtained. Nocturnal dry cough was consistently associated with moisture damage at school in each of the three countries: OR 1.15; 95% CI 1.00 to 1.30 with p for heterogeneity 0.54. Finnish children attending a moisture damaged school more often had wheeze (OR 1.36; CI 1.04 to 1.78), nasal symptoms (OR 1.34; CI 1.05 to 1.71) and respiratory-related school absence (OR 1.50; CI 1.10 to 2.03). No associations with these symptoms were found in the Netherlands or Spain (p for heterogeneity <0.05).

CONCLUSIONS

Moisture damage in schools may have adverse respiratory health effects in pupils. Finnish school children seem to be at higher risk, possibly due to quantitative and/or qualitative differences in exposure.

Molecular profiling of fungal communities in moisture damaged buildings before and after remediation--a comparison of culture-dependent and culture-independent methods

Background

Indoor microbial contamination due to excess moisture is an important contributor to human illness in both residential and occupational settings. However, the census of microorganisms in the indoor environment is limited by the use of selective, culture-based detection techniques. By using clone library sequencing of full-length internal transcribed spacer region combined with quantitative polymerase chain reaction (qPCR) for 69 fungal species or assay groups and cultivation, we have been able to generate a more comprehensive description of the total indoor mycoflora. Using this suite of methods, we assessed the impact of moisture damage on the fungal community composition of settled dust and building material samples (n = 8 and 16, correspondingly). Water-damaged buildings (n = 2) were examined pre- and post- remediation, and compared with undamaged reference buildings (n = 2).

Results

Culture-dependent and independent methods were consistent in the dominant fungal taxa in dust, but sequencing revealed a five to ten times higher diversity at the genus level than culture or qPCR. Previously unknown, verified fungal phylotypes were detected in dust, accounting for 12% of all diversity. Fungal diversity, especially within classes Dothideomycetes and Agaricomycetes tended to be higher in the water damaged buildings. Fungal phylotypes detected in building materials were present in dust samples, but their proportion of total fungi was similar for damaged and reference buildings. The quantitative correlation between clone library phylotype frequencies and qPCR counts was moderate (r = 0.59, p < 0.01).

Conclusions

We examined a small number of target buildings and found indications of elevated fungal diversity associated with water damage. Some of the fungi in dust were attributable to building growth, but more information on the material-associated communities is needed in order to understand the dynamics of microbial communities between building structures and dust. The sequencing-based method proved indispensable for describing the true fungal diversity in indoor environments. However, making conclusions concerning the effect of building conditions on building mycobiota using this methodology was complicated by the wide natural diversity in the dust samples, the incomplete knowledge of material-associated fungi fungi and the semiquantitative nature of sequencing based methods.

Remediating buildings damaged by dampness and mould for preventing or reducing respiratory tract symptoms, infections and asthma

BACKGROUND

Dampness and mould in buildings have been associated with adverse respiratory symptoms, asthma and respiratory infections of inhabitants. Moisture damage is a very common problem in private houses, workplaces and public buildings such as schools.

OBJECTIVES

To determine the effectiveness of remediating buildings damaged by dampness and mould in order to reduce or prevent respiratory tract symptoms, infections and symptoms of asthma.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2011, Issue 2), which contains the Cochrane Acute Respiratory Infections Group's Specialised Register, MEDLINE (1951 to June week 1, 2011), EMBASE (1974 to June 2011), CINAHL (1982 to June 2011), Science Citation Index (1973 to June 2011), Biosis Previews (1989 to June 2011), NIOSHTIC (1930 to November 2010) and CISDOC (1974 to November 2010).

SELECTION CRITERIA

Randomised controlled trials (RCTs), cluster-RCTs (cRCTs), interrupted time series studies and controlled before-after (CBA) studies of the effects of remediating dampness and mould in a building on respiratory symptoms, infections and asthma.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data and assessed the risk of bias in the included studies.

MAIN RESULTS

We included eight studies (6538 participants); two RCTs (294 participants), one cRCT (4407 participants) and five CBA studies (1837 participants). The interventions varied from thorough renovation to cleaning only. We found moderate-quality evidence in adults that repairing houses decreased asthma-related symptoms (among others, wheezing (odds ratio (OR) 0.64; 95% confidence interval (CI) 0.55 to 0.75) and respiratory infections (among others, rhinitis (OR 0.57; 95% CI 0.49 to 0.66)). For children, we found moderate-quality evidence that the number of acute care visits (among others mean difference (MD) -0.45; 95% CI -0.76 to -0.14)) decreased in the group receiving thorough remediation.One CBA study showed very low-quality evidence that after repairing a mould-damaged office building, asthma-related and other respiratory symptoms decreased. For children and staff in schools, there was very low-quality evidence that asthma-related and other respiratory symptoms in mould-damaged schools were similar to those of children and staff in non-damaged schools, both before and after intervention. For children, respiratory infections might have decreased after the intervention.

AUTHORS' CONCLUSIONS

We found moderate to very low-quality evidence that repairing mould-damaged houses and offices decreases asthma-related symptoms and respiratory infections compared to no intervention in adults. There is very low-quality evidence that although repairing schools did not significantly change respiratory symptoms in staff or children, pupils' visits to physicians due to a common cold were less frequent after remediation of the school. Better research, preferably with a cRCT design and with more validated outcome measures, is needed.

Neurobehavioral and pulmonary impairment in 105 adults with indoor exposure to molds compared to 100 exposed to chemicals

Patients exposed at home to molds and mycotoxins and those exposed to chemicals (CE) have many similar symptoms of eye, nose, and throat irritation and poor memory, concentration, and other neurobehavioral dysfunctions. To compare the neurobehavioral and pulmonary impairments associated with indoor exposures to mold and to chemicals. 105 consecutive adults exposed to molds (ME) indoors at home and 100 patients exposed to other chemicals were compared to 202 community referents without mold or chemical exposure. To assess brain functions, we measured 26 neurobehavioral functions. Medical and exposure histories, mood states score, and symptoms frequencies were obtained. Vital capacity and flows were measured by spirometry. Groups were compared by analysis of variance (ANOVA) after adjusting for age, educational attainment, and sex, by calculating predicted values (observed/predicted x 100 = % predicted). And p < .05 indicated statistical significance for total abnormalities, and test scores that were outside the confidence limits of the mean of the percentage predicted. People exposed to mold had a total of 6.1 abnormalities and those exposed to chemicals had 7.1 compared to 1.2 abnormalities in referents. Compared to referents, the exposed groups had balance decreased, longer reaction times, and blink reflex latentcies lengthened. Also, color discrimination errors were increased and visual field performances and grip strengths were reduced. The cognitive and memory performance measures were abnormal in both exposed groups. Culture Fair scores, digit symbol substitution, immediate and delayed verbal recall, picture completion, and information were reduced. Times for peg-placement and trail making A and B were increased. One difference was that chemically exposed patients had excess fingertip number writing errors, but the mold-exposed did not. Mood State scores and symptom frequencies were greater in both exposed groups than in referents. Vital capacities were reduced in both groups. Neurobehavioral and pulmonary impairments associated with exposures to indoor molds and mycotoxins were not different from those with various chemical exposures.

Indoor allergens in school and day care environments

Most studies that have examined exposure to indoor allergens have focused on home environments. However, allergen exposures can be encountered in environments other than the home. For example, many children spend a large part of their time in schools and day care facilities. Over the past 2 decades, a large number of studies have been conducted in school and day care environments. However, the role of indoor exposures in allergy and asthma development or morbidity in these settings is not well characterized. The purpose of this review is to evaluate the importance of indoor allergen exposures in school and day care settings. We summarize the key findings from recent scientific literature, describe exposure characteristics, discuss the role of these exposures in relation to asthma and allergy symptoms, and provide information on the effectiveness of published interventions.

Dampness and mold in the indoor environment: implications for asthma

This article presents epidemiologic findings pertinent to asthma and asthma-like symptoms in relation to exposure to dampness/mold in homes, schools, and workplaces. With regard to specific agents found in damp indoor environments that may play a role in asthma, it concentrates on mold (used synonymously with fungi) and includes some findings on bacteria. The literature on asthma in relation to dust mite or cockroach allergens is not addressed.

Public health and economic impact of dampness and mold

The public health risk and economic impact of dampness and mold exposures was assessed using current asthma as a health endpoint. Individual risk of current asthma from exposure to dampness and mold in homes from W.J. Fisk, Q. Lei-Gomez & M.J. Mendell [(2007) Indoor Air, [corrected] 17, 284-296], and [corrected] asthma risks calculated from additional studies that reported the prevalence of dampness and mold in homes were used to estimate the proportion of US current asthma cases that are attributable to dampness and mold exposure at 21% (95% confidence internal 12-29%). An examination of the literature covering dampness and mold in schools, offices, and institutional buildings, which is summarized in the Appendix, suggests that risks from exposure in these buildings are similar to risks from exposures in homes. Of the 21.8 million people reported to have asthma in the USA, approximately 4.6 (2.7-6.3) million cases are estimated to be attributable to dampness and mold exposure in the home. Estimates of the national cost of asthma from two prior studies were updated to 2004 and used to estimate the economic impact of dampness and mold exposures. By applying the attributable fraction to the updated national annual cost of asthma, the national annual cost of asthma that is attributable to dampness and mold exposure in the home is estimated to be $3.5 billion ($2.1-4.8 billion). Analysis indicates that exposure to dampness and mold in buildings poses significant public health and economic risks in the USA. These findings are compatible with public policies and programs that help control moisture and mold in buildings.

PRACTICAL IMPLICATIONS

There is a need to control moisture in both new and existing construction because of the significant health consequences that can result from dampness and mold. This paper demonstrates that dampness and mold in buildings is a significant public health problem with substantial economic impact.

Health effects of mold in children

Mold is ubiquitous, and exposure to mold and its products of metabolism is unavoidable, whether indoors or outdoors. Mold can produce a variety of adverse health outcomes by four scientifically validated pathophysiologic mechanisms: hypersensitivity, toxicity, infection, and irritation. Some adverse health outcomes have been attributed to mold for which mechanisms of injury are not well defined or are implausible. This article discusses these adverse health outcomes, focusing predominantly on those for which valid associations have been established.

Effects of moisture damage and renovation on microbial conditions and pupils' health in two schools--a longitudinal analysis of five years

Airborne microbes and pupils' symptoms were monitored in a moisture-damaged (index) school and a reference school for five consecutive years. These surveys were carried out in two separate years before the renovation of the index school, during the renovation, and one and two years after the renovation. Microbial concentrations were higher in the index school than those in the reference school before and during renovation, but afterwards, the levels decreased to the level of the reference school. The effect of remediation was seen as an altered mycobiota in the index school. Year-to-year variation of microbial concentrations, probably due to climatic factors, caused a peak in both schools but their difference remained. Several symptoms were more prevalent in the moisture-damaged school than in the reference school, but the differences disappeared during the renovations. These results emphasize the importance of using a reference building in assessing the microbial conditions of a moisture damaged building. Furthermore, microbial concentrations reflected well the technical condition of the construction, but the reported symptoms of the occupants did not strictly follow the timely fluctuation in microbial conditions.

Microbial Composition in Bioaerosols of a High-Throughput Chicken-Slaughtering Facility

The microbial composition of the air in various areas of a high-throughput chicken-slaughtering facility was investigated. Over a 4-mo period, 6 processing areas were sampled, and the influence of environmental factors was monitored. The highest counts of microorganisms were recorded in the initial stages of processing, comprising the receiving-killing and defeathering areas, whereas counts decreased toward the evisceration, air-chilling, packaging, and dispatch areas. Maximum microbial counts were as follows: coliforms, 4.9 x 10(3) cfu/m(3); Escherichia coli 3.4 x 10(3) cfu/m(3); Bacillus cereus, 5.0 x 10(4) cfu/m(3); Staphylococcus aureus, 1.6 x 10(4) cfu/m(3); Pseudomonas aeruginosa, 7.0 x 10(4) cfu/m(3); presumptive Salmonella spp., 1.5 x 10(4) cfu/m(3); Listeria monocytogenes, 1.6 x 10(4) cfu/m(3); and fungi, 1.4 x 10(4) cfu/m(3). Higher counts of airborne microorganisms found in the receiving-killing and defeathering areas indicate the importance of controlling microbial levels before processing to prevent the spread of organisms downstream. This should limit the risk of carrying over contaminants from areas known to generate high counts to areas where the final food product is exposed to air and surface contamination.

Spectrum of noninfectious health effects from molds

Molds are multicellular fungi that are ubiquitous in outdoor and indoor environments. For humans, they are both beneficial (for the production of antimicrobial agents, chemotherapeutic agents, and vitamins) and detrimental. Exposure to mold can occur through inhalation, ingestion, and touching moldy surfaces. Adverse health effects may occur through allergic, infectious, irritant, or toxic processes. The cause-and-effect relationship between mold exposure and allergic and infectious illnesses is well known. Exposures to toxins via the gastrointestinal tract also are well described. However, the cause-and-effect relationship between inhalational exposure to mold toxins and other untoward health effects (eg, acute idiopathic pulmonary hemorrhage in infants and other illnesses and health complaints) is controversial and requires additional investigation. In this report we examine evidence of fungal-related illnesses and the unique aspects of mold exposure to children. Mold-remediation procedures are also discussed.

Chemical and microbial exposures in a school building: adverse health effects in children

In this cross-sectional study, the authors examined the relationship between an unusual combination of indoor air contaminants in a school and adverse health effects among the attending children. A leaking roof and damp floors, together with gaseous leaks from the sewage system, led to a combined exposure of hydrocarbons, 2-ethylhexanol from plastic floor coverings, and moisture-associated microbes. The health status of 274 children in the school was assessed via repeated symptom questionnaires. Statistical analysis revealed a relationship between the indoor air contaminants and adverse health outcomes such as respiratory irritation, asthmatic symptoms, eye and general symptoms, and increased occurrence of common viral respiratory infections. No association was found between the exposures and doctor-diagnosed asthma, other allergic diseases, or bacterial respiratory infections. Chemical contaminants from the sewer system and damp construction materials were identified as the source of the problem. Remediation of the school building improved the indoor air quality and the health status of the children.

Allergy and "toxic mold syndrome"

BACKGROUND

"Toxic mold syndrome" is a controversial diagnosis associated with exposure to mold-contaminated environments. Molds are known to induce asthma and allergic rhinitis through IgE-mediated mechanisms, to cause hypersensitivity pneumonitis through other immune mechanisms, and to cause life-threatening primary and secondary infections in immunocompromised patients. Mold metabolites may be irritants and may be involved in "sick building syndrome." Patients with environmental mold exposure have presented with atypical constitutional and systemic symptoms, associating those symptoms with the contaminated environment.

OBJECTIVE

To characterize the clinical features and possible etiology of symptoms in patients with chief complaints related to mold exposure.

METHODS

Review of patients presenting to an allergy and asthma center with the chief complaint of toxic mold exposure. Symptoms were recorded, and physical examinations, skin prick/puncture tests, and intracutaneous tests were performed.

RESULTS

A total of 65 individuals aged 1 1/2 to 52 years were studied. Symptoms included rhinitis (62%), cough (52%), headache (34%), respiratory symptoms (34%), central nervous system symptoms (25%), and fatigue (23%). Physical examination revealed pale nasal mucosa, pharyngeal "cobblestoning," and rhinorrhea. Fifty-three percent (33/62) of the patients had skin reactions to molds.

CONCLUSIONS

Mold-exposed patients can present with a variety of IgE- and non-IgE-mediated symptoms. Mycotoxins, irritation by spores, or metabolites may be culprits in non-IgE presentations; environmental assays have not been perfected. Symptoms attributable to the toxic effects of molds and not attributable to IgE or other immune mechanisms need further evaluation as to pathogenesis. Allergic, rather than toxic, responses seemed to be the major cause of symptoms in the studied group.

Effects of moisture-damage repairs on microbial exposure and symptoms in schoolchildren

Effects of renovation on symptom prevalence and microbial status were studied in two moisture-damaged schools and in two non-damaged schools with longitudinal cross-sectional surveys before and after repairs. Over 1300 schoolchildren aged 6-17 returned questionnaires before and after repairs. After full renovation in one of the damaged schools, elevated concentrations and increased frequencies of indoor air fungi normalized and a significant decrease in the prevalence of 10 symptoms of 12 studied was observed among schoolchildren. No change in microbial conditions was seen after partial repairs in the other damaged school, and only slight improvement was observed in symptom prevalence. The change in the prevalence of symptoms in the reference schools was minor. The results suggest that increased symptom prevalence among schoolchildren in moisture-damaged schools can be managed with proper repair of the moisture damage.

PRACTICAL IMPLICATIONS

This longitudinal intervention study showed the positive effects of the moisture and mold damage repairs of a school building on children's health. The success necessitates however, a thorough renovation including appropriate ventilation. Monitoring of airborne viable microbes revealed the damage status of the building and thus could be used as a tool in evaluating the quality of repairs.

Building-related respiratory symptoms can be predicted with semi-quantitative indices of exposure to dampness and mold

Using a semi-quantitative mold exposure index, the National Institute for Occupational Safety and Health (NIOSH) investigated 13 college buildings to examine whether building-related respiratory symptoms among employees are associated with environmental exposure to mold and dampness in buildings. We collected data on upper and lower respiratory symptoms and their building-relatedness, and time spent in specific rooms with a self-administered questionnaires. Trained NIOSH industrial hygienists classified rooms for water stains, visible mold, mold odor, and moisture using semi-quantitative scales and then estimated individual exposure indices weighted by the time spent in specific rooms. The semi-quantitative exposure indices significantly predicted building-related respiratory symptoms, including wheeze [odds ratio (OR) = 2.3; 95% confidence interval (CI) = 1.1-4.5], chest tightness (OR = 2.2; 95% CI = 1.1-4.6), shortness of breath (OR = 2.7; 95% CI = 1.2-6.1), nasal (OR = 2.5; 95% CI = 1.3-4.7) and sinus (OR = 2.2; 95% CI = 1.2-4.1) symptoms, with exposure-response relationships. We found that conditions suggestive of indoor mold exposure at work were associated with building-related respiratory symptoms. Our findings suggest that observational semi-quantitative indices of exposure to dampness and mold can support action to prevent building-related respiratory diseases.

PRACTICAL IMPLICATIONS

Current air sampling methods have major limitations in assessing exposure to mold and other biological agents that may prevent the demonstration of associations of bioaerosol exposure with health. Our study demonstrates that semi-quantitative dampness/mold exposure indices, based solely on visual and olfactory observation and weighted by time spent in specific rooms, can predict existence of excessive building-related respiratory symptoms and diseases. Relative extent of water stains, visible mold, mold odor, or moisture can be used to prioritize remediation to reduce potential risk of building-related respiratory diseases. From a public health perspective, these observational findings justify action to correct water leaks and repair water damage in order to prevent building-related respiratory diseases. This approach can also be a basis for developing practical building-diagnostic tools for water-incursion.

Science-based recommendations to prevent or reduce potential exposure to biological, chemical, and physical agents in schools

The U.S. General Accounting Office (GAO) documented generally poor conditions of school facilities in the early 1990s. Previous papers examined, for time intervals ending before 2002, relationships between education facility indoor air and environmental quality (IEQ), including adequate ventilation, and occupant health and productivity. Research on IEQ related specifically to new or refurbished traditional school construction, or portable classrooms, is limited. A review of school IEQ literature through fall 2003 was conducted. Then, acknowledging the limited resources and competing priorities facing American schools, practical science-based, best practices recommendations to promote IEQ and hence prevent or reduce potential occupant exposure to biological, chemical, and physical agents of concern were proposed. Electronic search engines, conference proceedings, the Internet, and reference lists of peer-reviewed papers and reports were used. Eighteen best practices based on scientific references are presented.

Psychological, neuropsychological, and electrocortical effects of mixed mold exposure

The authors assessed the psychological, neuropsychological, and electrocortical effects of human exposure to mixed colonies of toxigenic molds. Patients (N = 182) with confirmed mold-exposure history completed clinical interviews, a symptom checklist (SCL-90-R), limited neuropsychological testing, quantitative electroencephalogram (QEEG) with neurometric analysis, and measures of mold exposure. Patients reported high levels of physical, cognitive, and emotional symptoms. Ratings on the SCL-90-R were "moderate" to "severe," with a factor reflecting situational depression accounting for most of the variance. Most of the patients were found to suffer from acute stress, adjustment disorder, or post-traumatic stress. Differential diagnosis confirmed an etiology of a combination of external stressors, along with organic metabolically based dysregulation of emotions and decreased cognitive functioning as a result of toxic or metabolic encephalopathy. Measures of toxic mold exposure predicted QEEG measures and neuropsychological test performance. QEEG results included narrowed frequency bands and increased power in the alpha and theta bands in the frontal areas of the cortex. These findings indicated a hypoactivation of the frontal cortex, possibly due to brainstem involvement and insufficient excitatory input from the reticular activating system. Neuropsychological testing revealed impairments similar to mild traumatic brain injury. In comparison with premorbid estimates of intelligence, findings of impaired functioning on multiple cognitive tasks predominated. A dose-response relationship between measures of mold exposure and abnormal neuropsychological test results and QEEG measures suggested that toxic mold causes significant problems in exposed individuals. Study limitations included lack of a comparison group, patient selection bias, and incomplete data sets that did not allow for comparisons among variables.

Indoor mold exposure associated with neurobehavioral and pulmonary impairment: a preliminary report

Recently, patients who have been exposed indoors to mixed molds, spores, and mycotoxins have reported asthma, airway irritation and bleeding, dizziness, and impaired memory and concentration, all of which suggest the presence of pulmonary and neurobehavioral problems. The author evaluated whether such patients had measurable pulmonary and neurobehavioral impairments by comparing consecutive cases in a series vs. a referent group. Sixty-five consecutive outpatients exposed to mold in their respective homes in Arizona, California, and Texas were compared with 202 community subjects who had no known mold or chemical exposures. Balance, choice reaction time, color discrimination, blink reflex, visual fields, grip, hearing, problem-solving, verbal recall, perceptual motor speed, and memory were measured. Medical histories, mood states, and symptom frequencies were recorded with checklists, and spirometry was used to measure various pulmonary volumes and flows. Neurobehavioral comparisons were made after individual measurements were adjusted for age, educational attainment, and sex. Significant differences between groups were assessed by analysis of variance; a p value of less than 0.05 was used for all statistical tests. The mold-exposed group exhibited decreased function for balance, reaction time, blink-reflex latency, color discrimination, visual fields, and grip, compared with referents. The exposed group's scores were reduced for the following tests: digit-symbol substitution, peg placement, trail making, verbal recall, and picture completion. Twenty-one of 26 functions tested were abnormal. Airway obstructions were found, and vital capacities were reduced. Mood state scores and symptom frequencies were elevated. The author concluded that indoor mold exposures were associated with neurobehavioral and pulmonary impairments that likely resulted from the presence of mycotoxins, such as trichothecenes.

Mixed mold mycotoxicosis: immunological changes in humans following exposure in water-damaged buildings

The study described was part of a larger multicenter investigation of patients with multiple health complaints attributable to confirmed exposure to mixed-molds infestation in water-damaged buildings. The authors present data on symptoms; clinical chemistries; abnormalities in pulmonary function; alterations in T, B, and natural killer (NK) cells; the presence of autoantibodies (i.e., antinuclear autoantibodies [ANA], autoantibodies against smooth muscle [ASM], and autoantibodies against central nervous system [CNS] and peripheral nervous system [PNS] myelins). A total of 209 adults, 42.7 +/- 16 yr of age (mean +/- standard deviation), were examined and tested with (a) self-administered weighted health history and symptom questionnaires; (b) standardized physical examinations; (c) complete blood counts and blood and urine chemistries; (d) urine and fecal cultures; (e) thyroid function tests (T4, free T3); (f) pulmonary function tests (forced vital capacity [FVC], forced expiratory volume in 1 sec [FEV1.0], and forced expiratory flow at 25%, 50%, 75%, and 25-75% of FVC [FEF25, FEF50, FEF75, and FEF2(25-75)]); (g) peripheral lymphocyte phenotypes (T, B, and NK cells) and mitogenesis determinations; and (h) a 13-item autoimmune panel. The molds-exposed patients reported a greater frequency and intensity of symptoms, particularly neurological and inflammatory symptoms, when compared with controls. The percentages of exposed individuals with increased lymphocyte phenotypes were: B cells (CD20+), 75.6%; CD5+CD25+, 68.9%; CD3+CD26+, 91.2%; CD8+HLR-DR+, 62%; and CD8+CD38+, 56.6%; whereas other phenotypes were decreased: CD8+CD11b+, 15.6% and CD3-CD16+CD56+, 38.5%. Mitogenesis to phytohemagglutinin was decreased in 26.2% of the exposed patients, but only 5.9% had decreased response to concanavalin A. Abnormally high levels of ANA, ASM, and CNS myelin (immunoglobulins [Ig]G, IgM, IgA) and PNS myelin (IgG, IgM, IgA) were found; odds ratios for each were significant at 95% confidence intervals, showing an increased risk for autoimmunity. The authors conclude that exposure to mixed molds and their associated mycotoxins in water-damaged buildings leads to multiple health problems involving the CNS and the immune system, in addition to pulmonary effects and allergies. Mold exposure also initiates inflammatory processes. The authors propose the term "mixed mold mycotoxicosis" for the multisystem illness observed in these patients.

Estimating effects of moisture damage repairs on students' health-a long-term intervention study

Health symptom questionnaire responses were collected from upper secondary and high school students (n=245) before comprehensive repairs of moisture damage in the school. The questionnaire study was repeated 1 year (n=227), 3 years (n=256), and 5 years (n=233) after the repairs. The data were analyzed both in cross-sectional design including all respondents, and longitudinally including paired observations of those individuals who had responded both before and after the repairs. In addition, the effect of intervention on health symptoms was analyzed using generalized estimating equations (GEEs), taking into account within-subject correlation between repeated measurements. Compared to the situation before the repairs, the situation after the repairs was significantly improved in most of the 20 symptoms studied among the cross-sectional study populations. However, improvement was not so clear in the paired analysis and GEE analysis among the students who responded to three repeated questionnaires. The results indicate that the repairs succeeded in the sense that new cases of symptomatic students were no longer expected. However, the reversibility of symptoms among the group of exposed individuals may need to be considered separately.

Environmental control for fungal allergen exposure

With our limited knowledge of the mold allergens, we must rely on common sense to reduce environmental exposure for patients who are allergic to mold. We understand that the first step is moisture control. Appropriate building design, keeping rainwater and ground water away from the interior, accomplishes this. In addition, the heating ventilation and air conditioning system must be appropriately designed and maintained. Functional maintenance of inside water sources such as free water from plumbing, appliances, and showers can prevent damaging leaks. Indoor humidity or water vapor must be controlled and maintained to prevent condensation on walls or in microenvironments, such as attics, bedrooms, basements, and beneath wall-to-wall carpeting. Few abatement trials have been published, but several suggest that such measures can reduce mold exposure.

Indoor mold spore exposure: a possible factor in the etiology of multifocal choroiditis

PURPOSE

To report on the correlation between indoor mold exposure and a case of multifocal choroiditis (MFC).

DESIGN

Observational case report.

METHODS

A 37-year-old woman diagnosed with MFC who had had extensive mold exposure underwent an allergic evaluation, including a comprehensive environmental history, physical examination, radioallergosorbent test, and skin testing.

RESULTS

The patient's vision deteriorated after numerous recurrences of MFC triggered by exposure to extremely high mold environments (mold counts recorded between 3,000 and 13,000 mold spores/m(3)).

CONCLUSIONS

Exposure to high indoor mold count environments may be a factor in the etiology of MFC. Further studies are indicated.

Fungal contamination of elementary schools: a new environmental hazard

BACKGROUND

Sensitivity to fungi is a significant cause of allergic diseases, and prolonged indoor exposure to fungi is a growing health concern.

OBJECTIVE

This study evaluates the health effects of mold-contaminated schools on students and teachers. A discussion of the effectiveness of current methods for evaluating these schools, with a focus on the importance of using total mold spore counts, is also provided.

METHODS

Two Connecticut public schools were tested using multiple air quality testing methods, with the standard for a healthy indoor environment being total mold spore counts lower than 1,000 spores/m3. The health impact of the mold exposure at each school was evaluated using the validated Rhinitis Outcomes Questionnaire.

RESULTS

The testing of the first school found indoor mold counts ranging from 6,000 to 50,000 spores/m3. Eighty-five of the students and teachers reported significant allergic symptoms to the school nurse. This school is currently being demolished. More than 2 years after the exposure ended, a number of occupants of the school continue to have elevated symptoms compared with before their exposure to the school. The testing of the second school revealed total mold spore counts ranging between 2,000 and 9,000 spores/m3, qualifying it an unhealthy environment in need of immediate remediation. Students reported significant allergic symptoms from exposure to certain rooms that are currently being remediated.

CONCLUSIONS

Because of the negative impact on health that indoor mold exposure has, particularly in atopic patients, schools should be routinely tested for fungal contamination. Total mold spore counts should be performed using volumetric air sampling such as the Allergenco MK-3 (Allergenco, San Antonio, TX) because testing air quality via semiquantitative culture sampling alone does not give a true reflection of the extent of fungal contamination. Finally, the standard for a healthy indoor environment should be defined as having <1,000 spores/m3.

Indoor mold, toxigenic fungi, and Stachybotrys chartarum: infectious disease perspective

Damp buildings often have a moldy smell or obvious mold growth; some molds are human pathogens. This has caused concern regarding health effects of moldy indoor environments and has resulted in many studies of moisture- and mold-damaged buildings. Recently, there have been reports of severe illness as a result of indoor mold exposure, particularly due to Stachybotrys chartarum. While many authors describe a direct relationship between fungal contamination and illness, close examination of the literature reveals a confusing picture. Here, we review the evidence regarding indoor mold exposure and mycotoxicosis, with an emphasis on S. chartarum. We also examine possible end-organ effects, including pulmonary, immunologic, neurologic, and oncologic disorders. We discuss the Cleveland infant idiopathic pulmonary hemorrhage reports in detail, since they provided important impetus for concerns about Stachybotrys. Some valid concerns exist regarding the relationship between indoor mold exposure and human disease. Review of the literature reveals certain fungus-disease associations in humans, including ergotism (Claviceps species), alimentary toxic aleukia (Fusarium), and liver disease (Aspergillys). While many papers suggest a similar relationship between Stachybotrys and human disease, the studies nearly uniformly suffer from significant methodological flaws, making their findings inconclusive. As a result, we have not found well-substantiated supportive evidence of serious illness due to Stachybotrys exposure in the contemporary environment. To address issues of indoor mold-related illness, there is an urgent need for studies using objective markers of illness, relevant animal models, proper epidemiologic techniques, and examination of confounding factors.

Immunoglobulin G antibodies of children exposed to microorganisms in a water-damaged school

The aim of this study was to determine whether exposure to fungi (molds and yeasts) among children attending a water-damaged school was reflected by the children's immunoglobulin G (IgG) response to microorganisms typical of water damage and whether the presence of these IgG antibodies was associated with respiratory symptoms and morbidity. The relationships between positive IgG antibodies and atopy, described as elevated allergen-specific immunoglobulin E (IgE) antibodies, were also examined. The study population consisted of a randomly selected group of exposed children attending a water-damaged school and a group of unexposed children of the same age. Serum samples for analyses of IgG and IgE antibodies were drawn from the children. The respiratory morbidity, the number of positive IgG antibodies to nine microorganisms indicating water damage, and IgE sensitization to common environmental allergens (Phadiatop) were studied. The mean number of positive IgG findings was significantly higher among the exposed children. The number of positive IgG antibodies did not correlate with respiratory illnesses or symptoms at the individual level even though the exposed children who had positive IgG antibodies to four or more microorganisms in the total group comparison tended to have higher respiratory morbidity. In the exposed group, a negative correlation was found between the number of positive IgG antibodies and the total value of allergen-specific IgE antibodies. As among adults exposed to microorganisms at work, IgG antibodies in children seem to be a relevant indicator of exposure to microorganisms in a water-damaged school on the group level.

Health effects of mold exposure in public schools

This paper profiles the impact of mold exposure on the health of students, teachers, and staff in two public elementary schools in Connecticut, and explains how the air quality in each school was tested, and how the health of teachers and students was assessed. It also proposes standards for testing indoor air quality and evaluating the health impact of indoor mold exposure on students, teachers, and staff members.

Increased prevalence of atopy among children exposed to mold in a school building

BACKGROUND

The purpose of this study was to assess the occurrence of immunoglobulin E sensitization to common environmental allergens (atopy) and new allergic diseases among schoolchildren after starting school in a water-damaged school building. The staff and pupils of a Finnish elementary school with visible water damage and mold complained of respiratory and skin symptoms. The school building was examined and widespread moisture damage was found. A control school with no visible water damage was also examined. No indication of exceptional microbial growth was found in the samples taken from this school.

METHODS

History of allergic diseases and the year of diagnosis were established by a questionnaire. IgE antibodies to the common environmental allergens were determined from randomly selcted groups from both schools.

RESULTS

Elevated IgE values were significantly more common among the exposed children, as was the occurrence of new allergic diseases after the children started at the school.

CONCLUSIONS

The odds ratios for the IgE values of the study groups indicated a possible relationship between exposure to microorganisms and IgE sensitization. Exposure to spores, toxins, and other metabolites of molds may have complex results with unknown immunogenic effects that may act as a nonspecific trigger for allergic sensitization leading to the development of atopy.