Effects of damp and mould in the home on respiratory health: a review of the literature

[Medical clinical diagnostics for indoor mould exposure - Update 2023 (AWMF Register No. 161/001)]

This article is an abridged version of the updated AWMF mould guideline "Medical clinical diagnostics in case of indoor mould exposure - Update 2023", presented in July 2023 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with German and Austrian scientific medical societies, and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. There is no evidence for a causal relationship between moisture/mould damage and human diseases, mainly because of the ubiquitous presence of fungi and hitherto inadequate diagnostic methods. Sufficient evidence for an association between moisture/mould damage and the following health effects has been established for: allergic respiratory diseases, allergic rhinitis, allergic rhino-conjunctivitis, allergic bronchopulmonary aspergillosis (ABPA), other allergic bronchopulmonary mycosis (ABPM), aspergilloma, Aspergillus bronchitis, asthma (manifestation, progression, exacerbation), bronchitis (acute, chronic), community-acquired Aspergillus pneumonia, hypersensitivity pneumonitis (HP; extrinsic allergic alveolitis (EEA)), invasive Aspergillosis, mycoses, organic dust toxic syndrome (ODTS) [workplace exposure], promotion of respiratory infections, pulmonary aspergillosis (subacute, chronic), and rhinosinusitis (acute, chronically invasive, or granulomatous, allergic). In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitization prevalence of 3-22,5 % in the general population across Europe. Limited or suspected evidence for an association exist with respect to atopic eczema (atopic dermatitis, neurodermatitis; manifestation), chronic obstructive pulmonary disease (COPD), mood disorders, mucous membrane irritation (MMI), odor effects, and sarcoidosis. (iv) Inadequate or insufficient evidence for an association exist for acute idiopathic pulmonary hemorrhage in infants, airborne transmitted mycotoxicosis, arthritis, autoimmune diseases, cancer, chronic fatigue syndrome (CFS), endocrinopathies, gastrointestinal effects, multiple chemical sensitivity (MCS), multiple sclerosis, neuropsychological effects, neurotoxic effects, renal effects, reproductive disorders, rheumatism, sick building syndrome (SBS), sudden infant death syndrome, teratogenicity, thyroid diseases, and urticaria.The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 (Aspergillus fumigatus, A. flavus) of the German Biological Agents Act (Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, water activity, temperature and above all the growth substrates.In case of indoor moisture/mould damage, everyone can be affected by odor effects and/or mood disorders.However, this is not an acute health hazard. Predisposing factors for odor effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly regarding infection risk are immunocompromised persons according to the classification of the German Commission for Hospital Hygiene and Infection Prevention (Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch-Institute (RKI), persons suffering from severe influenza, persons suffering from severe COVID-19, and persons with cystic fibrosis (mucoviscidosis); with regard to allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma must be protected. The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections, the reader is referred to the specific guidelines. Regarding mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medical point of view, it is important that indoor mould infestation in relevant magnitudes cannot be tolerated for precautionary reasons.For evaluation of mould damage in the indoor environment and appropriate remedial procedures, the reader is referred to the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

Poor housing quality and the health of newborns and young children

This study uses linked administrative data on live births, hospital stays, and census records for children born in Hungary between 2006 and 2011 to examine the relationship between poor housing quality and the health of newborns and children aged 1-2 years. We show that poor housing quality, defined as lack of access to basic sanitation and exposure to polluting heating, is not a negligible problem even in a high-income EU country like Hungary. This is particularly the case for disadvantaged children, 20-25% of whom live in extremely poor-quality homes. Next, we provide evidence that poor housing quality is strongly associated with lower health at birth and a higher number of days spent in inpatient care at the age of 1-2 years. These results indicate that lack of access to basic sanitation, hygiene, and non-polluting heating and their health impacts cannot be considered as the exclusive problem for low- and middle-income countries. In high-income countries, there is also a need for public policy programs that identify those affected by poor housing quality and offer them potential solutions to reduce the adverse effects on their health.

An unusually high prevalence of allergic rhinitis at high altitudes in 6-7 year old children - An epidemiological study

Objectives

To compare the epidemiology and disease patterns of allergic rhinitis (AR) at 2 different altitudes in children aged 6-7 years, and subsequently to compare with and augment data from international studies.

Materials and methods

This is a multistage, clustered and stratified random sample study. The study area comprises 2 distinct areas within Yunnan Province, China. Low altitude was represented by Xishuangbanna Prefecture (XB), while high altitude was represented by Diqing Prefecture (DiQ). Each study area was subdivided into 3 sub-areas, and children aged 6-7 years were randomly sampled based on proportion-weighted sampling. The area studied includes the well-known area of Shangri-La city. Questionnaires were distributed and jointly completed by study participants and their parents or guardians, under the guidance of professional medical staff.

Results

2796 valid questionnaires out of 2933 distributed were obtained (survey response rate 95.3%). The prevalence of AR is statistically significantly higher at high altitude (DiQ, 36.0%, 95%CI 33.2-38.8) as compared to low altitude (XB, 19.7%, 95%CI 17.8-21.6) (p < 0.001). Both areas studied had a greater prevalence of AR compared to international data. In both XB and DiQ, male gender, history of early antibiotic use, urban place of birth and place of residence, presence of smokers within the same household, family history of allergic diseases (such as atopic dermatitis), as well as higher parental educational level were all associated with a higher prevalence of AR (p < 0.05). In DiQ, the prevalence of AR in Han ethnicity was greater than that of ethnic minorities (p < 0.05). In XB, being a single child was associated with an increased prevalence of AR compared to those who had siblings (p < 0.05).

Conclusion

Our study found that the prevalence of AR is relatively greater at higher altitudes. Genetic and environmental factors both play an important role in the pathogenesis of AR. While altitude may be an important environmental factor, confounding factors may include humidity, temperature and distribution pattern of common aeroallergens.

Substandard housing and the risk of COVID-19 infection and disease severity: A retrospective cohort study

In this study we examine associations between substandard housing and the risk of COVID-19 infection and severity during the first year of the pandemic by linking individual-level housing and clinical datasets. Residents of Chelsea, Massachusetts who were tested for COVID-19 at any Mass General Brigham testing site and who lived at a property that had received a city housing inspection were included (N = 2873). Chelsea is a densely populated city with a high prevalence of substandard housing. Inspected properties with housing code violations were considered substandard; inspected properties without violations were considered adequate. COVID-19 infection was defined as any positive PCR test, and severe disease defined as hospitalization with COVID-19. We used a propensity score design to match individuals on variables including age, race, sex, and income. In the severity model, we also matched on ten comorbidities. We estimated the risk of COVID-19 infection and severity associated with substandard housing using Cox Proportional Hazards models for lockdown, the first phase of reopening, and the full study period. In our sample, 32% (919/2873) of individuals tested positive for COVID-19 and 5.9% (135/2297) had severe disease. During lockdown, substandard housing was associated with a 48% increased risk of COVID-19 infection (95%CI 1.1-2.0, p = 0.006). Through Phase 1 reopening, substandard housing was associated with a 39% increased infection risk (95%CI 1.1-1.8, p = 0.020). The difference in risk attenuated over the full study period. There was no difference in severe disease risk between the two groups. The increased risk, observed only during lockdown and early reopening - when residents were most exposed to their housing - strengthens claims that substandard housing conveys higher infection risk. The results demonstrate the value of combining cross-sector datasets. Existing city housing data can be leveraged 1) to identify and prioritize high-risk areas for future pandemic response, and 2) for longer-term housing solutions.

Healthcare utilization for asthma exacerbation among children of migrant and seasonal farmworkers

Latino children of Migrant and Seasonal Farmworkers (MSFWs) with asthma are at risk for poor health outcomes due to medical access barriers. We compared differences in acute care utilization for asthma exacerbations among migrant and non-migrant Latino and non-Hispanic white (NHW) children at U.S. community health centers. A retrospective observational study utilizing electronic health record data from the ADVANCE Clinical Research Network of United States community health centers included 13,423 children ages 3-17 with a primary care visit between 2005 and 2017 from eight states. Emergency department (ED) and hospitalization data came from Oregon Medicaid claims. Outcomes included acute clinic visits, ED visits, and hospitalizations for asthma exacerbation. Regression analyses adjusted for patient-level covariates. Latino children had higher odds of acute clinic visits for asthma exacerbation compared to NHW children (MSFW odds ratio [OR] = 1.17, 95 % CI = 1.03-1.33; without migrant status OR = 1.13, 95 % CI = 1.03-1.23). MSFW children using Oregon Medicaid had fewer ED visits (rate ratio [RR] = 0.72, 95 % CI = 0.52-0.99) and hospitalizations (RR = 0.47, 95 % CI = 0.26-0.86) compared to NHW children. Increased community health center visits may help mitigate disparities in acute asthma care for MSFW children.

Work in nursing homes and occupational exposure to endotoxin and bacterial and fungal species

Indoor microbial exposure may cause negative health effects. Only little is known about the occupational microbial exposure in nursing homes and the factors that influence the exposure. The exposure in nursing homes may be increased due to close contact with elderly persons who may carry infectious or antimicrobial-resistant microorganisms and due to handling of laundry, such as used clothing and bed linen. We investigated the microbial exposure in 5 nursing homes in Denmark, by use of personal bioaerosol samples from different groups of staff members taken during a typical working day, stationary bioaerosol measurements taken during various work tasks, sedimented dust samples, environmental surface swabs, and swabs from staff members' hands. From the samples, we explored bacterial and fungal concentrations and species composition, endotoxin levels, and antimicrobial resistance in Aspergillus fumigatus isolates. Microbial concentrations from personal exposure samples differed among professions, and geometric means (GM) were 2,159 cfu/m3 (84 to 1.5 × 105) for bacteria incubated on nutrient agar, 1,745 cfu/m3 (82 to 2.0 × 104) for bacteria cultivated on a Staphylococcus selective agar, and 16 cfu/m3 air for potential pathogenic fungi incubated at 37 °C (below detection limit to 257). Bacterial exposures were elevated during bed making. On surfaces, the highest bacterial concentrations were found on bed railings. The majority of bacterial species found were related to the human skin microflora, such as different Staphylococcus and Corynebacterium species. Endotoxin levels ranged from 0.02 to 59.0 EU/m3, with a GM of 1.5 EU/m3. Of 40 tested A. fumigatus isolates, we found one multiresistant isolate, which was resistant towards both itraconazole and voriconazole, and one isolate resistant towards amphotericin B. In conclusion, we give an overview of the general microbial exposure in nursing homes and show that microbial exposures are higher for staff with more care and nursing tasks compared with administrative staff.

Environmental justice and allergic disease: A Work Group Report of the AAAAI Environmental Exposure and Respiratory Health Committee and the Diversity, Equity and Inclusion Committee

Environmental justice is the concept that all people have the right to live in a healthy environment, to be protected against environmental hazards, and to participate in decisions affecting their communities. Communities of color and low-income populations live, work, and play in environments with disproportionate exposure to hazards associated with allergic disease. This unequal distribution of hazards has contributed to health disparities and is largely the result of systemic racism that promotes segregation of neighborhoods, disinvestment in predominantly racial/ethnic minority neighborhoods, and discriminatory housing, employment, and lending practices. The AAAAI Environmental Exposure and Respiratory Health Committee and Diversity, Equity and Inclusion Committee jointly developed this report to improve allergy/immunology specialists' awareness of environmental injustice, its roots in systemic racism, and its impact on health disparities in allergic disease. We present evidence supporting the relationship between exposure to environmental hazards, particularly at the neighborhood level, and the disproportionately high incidence and poor outcomes from allergic diseases in marginalized populations. Achieving environmental justice requires investment in at-risk communities to increase access to safe housing, clean air and water, employment opportunities, education, nutrition, and health care. Through policies that promote environmental justice, we can achieve greater health equity in allergic disease.

A Systematic Review of Associations between Energy Use, Fuel Poverty, Energy Efficiency Improvements and Health

Energy use in buildings can influence the indoor environment. Studies on green buildings, energy saving measures, energy use, fuel poverty, and ventilation have been reviewed, following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The database PubMed was searched for articles published up to 1 October 2020. In total, 68 relevant peer-reviewed epidemiological or exposure studies on radon, biological agents, and chemicals were included. The main aim was to assess current knowledge on how energy saving measures and energy use can influence health. The included studies concluded that buildings classified as green buildings can improve health. More efficient heating and increased thermal insulation can improve health in homes experiencing fuel poverty. However, energy-saving measures in airtight buildings and thermal insulation without installation of mechanical ventilation can impair health. Energy efficiency retrofits can increase indoor radon which can cause lung cancer. Installation of a mechanical ventilation systems can solve many of the negative effects linked to airtight buildings and energy efficiency retrofits. However, higher ventilation flow can increase the indoor exposure to outdoor air pollutants in areas with high levels of outdoor air pollution. Finally, future research needs concerning energy aspects of buildings and health were identified.

Prototyping a low-cost residential air quality device using ultraviolet germicidal irradiation (UVGI) light

Many New Zealand residential dwellings suffer from dampness and fungi during the winter, which can cause respiratory health problems. This can be due to poor insulation and ventilation, and the situation worsens when residents cannot afford to heat the dwelling. The main aim of this paper is to modify an existing dehumidifier so that it can remove moisture, heat the living space and reduce fungi growth and bacteria. To achieve that, we installed ultraviolet germicidal lights (UVGI) in an existing dehumidifier with a total cost of USD $150.7 (NZD $213.76). The UVGI lights are known to be efficient in destroying the DNA of fungi and bacteria. The results show that the device reduced the fungi growth and did increase the room temperature because the dehumidifier captured two litres of water over 24 h of testing. The proposed device did achieve a reduction in particulate matters, from 0.9 μ g / m 3 to 0.14 μ g / m 3 and an acceptable range of relative humidity below 50%, which reduces the favourable conditions for fungi growth. Therefore, our proposed low-cost device does improve the indoor air quality (IAQ) in the living space.

Spread of respiratory infections in student dormitories in China

OBJECTIVES

Student dormitory rooms in China are characterized by small space and high occupancy. This study aims to investigate infection rates for common colds and influenza among college students in a Chinese university and their association with the dormitory environment.

METHODS

This study involved two phases. In Phase I, 2978 students living in 998 dorm rooms in 12 buildings responded to a questionnaire survey on infections in four seasons. In Phase II, based on the data obtained from the questionnaire survey, we selected 242 dorm rooms to measure air temperature, relative humidity and CO₂ concentration in both summer and winter. Ventilation rates at night were calculated based on measured CO₂ concentrations.

RESULTS

We found that students had infections more often in winter, and in rooms with higher occupancy and dampness problems. The median value of the ventilation rate in dorm rooms in summer was 10.7 L/s per person, while it was 4.10 L/s per person in winter. There were significant associations between ventilation rate per person at night and common cold and influenza both in summer and winter (p < 0.05). A combination of dampness and low ventilation rate significantly increased the risk of common colds (adjusted odds ratios, AOR: 1.26-1.91) and influenza (AOR: 1.49-2.20).

CONCLUSION

College students living in a crowded dormitory room with low ventilation and dampness problems had more common colds and influenza infections.

Chitinase-Induced Airway Hyperreactivity and Inflammation in a Mouse Model of Nonallergic Asthma

INTRODUCTION

Environmental exposure to mites and fungi has been proposed to critically contribute to the development of IgE-mediated asthma. A common denominator of such organisms is chitin. Human chitinases have been reported to be upregulated by interleukin-13 secreted in the context of Th2-type immune responses and to induce asthma. We assessed whether chitin-containing components induced chitinases in an innate immune-dependent way and whether this results in bronchial hyperresponsiveness.

MATERIALS AND METHODS

Monocyte/macrophage cell lines were stimulated with chitin-containing or bacterial components in vitro. Chitinase activity in the supernatant and the expression of the chitotriosidase gene were measured by enzyme assay and quantitative PCR, respectively. Non-sensitized mice were stimulated with chitin-containing components intranasally, and a chitinase inhibitor was administered intraperitoneally. As markers for inflammation leukocytes were counted in the bronchoalveolar lavage (BAL) fluid, and airway hyperresponsiveness was assessed via methacholine challenge.

RESULTS

We found both whole chitin-containing dust mites as well as the fungal cell wall component zymosan A but not endotoxin-induced chitinase activity and chitotriosidase gene expression in vitro. The intranasal application of zymosan A into mice led to the induction of chitinase activity in the BAL fluid and to bronchial hyperresponsiveness, which could be reduced by applying the chitinase inhibitor allosamidin.

DISCUSSION

We propose that environmental exposure to mites and fungi leads to the induction of chitinase, which in turn favors the development of bronchial hyperreactivity in an IgE-independent manner.

Preliminary Studies on Fungal Contamination of Two Rupestrian Churches from Matera (Southern Italy)

The Sassi, a UNESCO World Heritage Site and its rupestrian churches, are richly decorated and visited by thousands of visitors every year. It is important to preserve this heritage which shows signs of deterioration due to abiotic and/or biotic factors. Aiming to carry out in the future an environmental-friendly restoration, a screening of the fungi present on walls and frescoes of two rupestrian churches “Santa Lucia alle Malve” and “La Madonna dei derelitti” located, respectively, in the “Sasso Caveoso” and in the “Sasso Barisano” was performed. Isolation and characterization of fungal species from investigated sites was carried out. Total genomic DNA (gDNA) was extracted from pure fungal cultures and subsequently utilized in PCRs using primers that amplify a portion of the ribosomal DNA (ITS5/ITS4) or the β-tubulin gene (Bt2a/Bt2b). The amplicons were directly sequenced. Obtained nucleotide sequences were compared to those present in the GenBank (NCBI) showing a very high similarity (99–100%) with the following species: Parengyodontium album, Alternaria alternata, Cladosporium cladosporioides, Lecanicillium psalliotae, Meyerozyma guilliermondii and Botryotrichum atrogriseum. All sequences from this study were deposited in the EMBL database. Detailed knowledge about fungi isolated from stone is indispensable not only to counter/reduce the structural and aesthetic damage but also to protect the health of both guardians and visitors who may develop different pathologies due to the spores diffused in the environment.

Fungal spore adhesion on glycidoxypropyltrimethoxy silane modified silica nanoparticle surfaces as revealed by single cell force spectroscopy

Thin film coatings prepared from commercially available glycidoxypropyltrimethoxysilane (GPS) modified silica nanoparticles (SiNPs) (Bindzil® CC301 and Bindzil® CC302) have previously shown excellent antifouling performance against a broad range of microbes [Molino et al., "Hydration layer structure of biofouling-resistant nanoparticles," ACS Nano 12, 11610 (2018)]. In this work, single cell force spectroscopy (SCFS) was used to measure the biological interactions between Epicoccum nigrum fungal spores and the same silica nanoparticle-based surfaces used in the aforementioned study, including a: glass coverslip, unmodified SiNP coatings, and both low (Bindzil® CC301) and high density (CC302) GPS functionalized SiNP coatings as a function of NaCl concentration. From the SCFS curves, the spore adhesion to the surface was greatest on the glass coverslip (20-80 nN) followed by the unmodified SiNP (3-5 nN) across all salt concentrations. Upon approach to both surfaces, the spores showed a long-range attraction generally with a profile characteristic of biointeractions and likely those of the outer cell wall structures or biological constituents. The attractive force allowed the spores to initially adhere to the surface and was found to be linearly proportional to the spore adhesion. In comparison, both high and low density GPS-SINP significantly reduced the spore adhesion (0.5-0.9 nN). In addition, the spore adhesion on high density GPS-SiNP occurred in only 14%-27% of SCFS curves (40%-48% for low density GPS-SiNP) compared to 83%-97% for the unmodified SiNP, indicating that in most cases the GPS functionalization completely prevented spore adhesion. The GPS-SiNP surfaces conversely showed a long-range electrostatic repulsion at low 1mM NaCl that was replaced by short-range repulsion at the higher salt concentrations. From the findings, it is proposed that the attractive force is a critical step in initial adhesion processes of the spore. The effective antifouling properties of the GPS are attributed to the ability to negate the attractive forces, either through electrostatic repulsion in low salt conditions and primarily from short-range repulsion correlating to the previously reported combined steric-hydration effect of the GPS functionalization on SiNP coatings.

Critical failures in the use of home ventilation medical equipment

Home ventilation involves the use of medical devices at patient's home by personnel who are not healthcare practitioners. This implies new potential risks not fully addressed by current standards and guidelines. A methodological approach to investigate potential failures and define improvement actions to address the dangerous potential situations in HV is required.

A multidisciplinary team performed an extended version of Failure Mode, Effect and Criticality Analysis (FMECA) to analyse the home ventilation service provided by the Local Healthcare Unit of Naples (ASL NA1) that assisted 60 homebound ventilator dependent patients. The failures were identified in three risk areas: device, electrical system & fire hazard, and indoor air quality. The corrective actions were formulated with two extra steps: identification of critical failures with a threshold applied to the risk priority number and analysis of causes by means of contributory factors (Organization, Technology, Information, and Structure) based on Reason's theory of failures.

22 of 86 potential failures were identified as critical. Specific corrective actions were addressed and proposed through contributory factors to improve the overall quality of home ventilation service.

The use of this systemic approach oriented the improvements to reduce the harms caused by vulnerabilities in high-risk care service as life support home ventilation.

The relationship between individual-level deprivation and health-related quality of life

OBJECTIVE

To examine the association between individual-level deprivation and health-related quality of life (HRQL) in the general population.

METHODS

Data from a population-based survey in the Canadian province of Alberta were used. Individual-level deprivation was assessed using the Canadian Deprivation Index (CDI) and the Ontario Deprivation Index (ODI). HRQL was assessed using the EQ-5D-5 L. Differences in problems in the EQ-5D-5 L dimensions, index and visual analogue scale (VAS) scores across levels of deprivation were examined. Multivariate logistic and linear regression models adjusted for socio-demographic and other characteristics were used to examine the independent association between deprivation and HRQL.

RESULTS

Of the 6314 respondents, 39% were aged between 18 and 44 years and 38% between 45 and 64 years; 60% were female. Mean EQ-5D-5 L index and VAS scores were 0.85 (standard deviation [SD] 0.14) and 79.6 (SD 17.7), respectively. Almost one-third (30.6%) of respondents reported no problems on all EQ-5D-5 L dimensions. Few participants reported some problems with mobility (23.8%), self-care (6.2%) and usual activities (25.2%), while 59.3 and 35.5% reported some levels of pain/discomfort and anxiety/depression, respectively. Differences between the most and least deprived in reporting problems in EQ-5D-5 L dimensions, index and VAS scores were statistically significant and clinically important. In adjusted regression models for both deprivation indices, the least well-off, compared to the most well-off, had higher likelihood of reporting problems in all EQ-5D-5 L dimensions. Compared to the most well-off, the least well-off had an EQ-5D-5 L index score decrement of 0.18 (p < 0.01) and 0.17 (p < 0.01) for the CDI and ODI, respectively. Similarly, an inverse association was found between the VAS score and the CDI (β = - 17.3, p < 0.01) as well as the ODI (β = - 13.3, p < 0.01).

CONCLUSION

Individual-level deprivation is associated with worse HRQL. Poverty reduction strategies should consider the effects of not only neighbourhood-level deprivation, but also that of individual-level deprivation to improve overall health.

Household dampness-related exposures in relation to childhood asthma and rhinitis in China: A multicentre observational study

During 2010-2012, we conducted an observational study on household environment and health outcomes among 40,010 preschool children from seven cities of China. Here we examined associations of six dampness-related indicators (visible mold spots, visible damp stains, damp clothing and/or bedding, water damage, condensation on windowpane, moldy odor) in the current residence and three dampness-related indicators (visible mold spots, condensation on windowpane, moldy odor) in the early residence with childhood asthma and rhinitis. In the multi-level logistic regression analyses, visible mold spots and visible damp stains in the current residence were significantly associated with the increased odds of doctor-diagnosed asthma and allergic rhinitis during lifetime-ever (adjusted odd ratios (AORs) range: 1.18-1.35). All dampness-related indicators were significantly associated with increased odds of wheeze and rhinitis during lifetime-ever and in the past 12 months (AORs range: 1.16-2.64). The cumulative numbers of damp indicators had positively dose-response relationships with the increased odds of the studied diseases. These associations for wheeze and rhinitis were similar between northern children and southern children. Similar results were found in the sensitive analyses among children without a family history of allergies and among children without asthma and allergic rhinitis. For 3-6 years-old children in mainland of China in 2011, we speculated that about 90,000 (2.02%) children with asthma and about 59,000 (1.09%) children with allergic rhinitis could be attributable to exposing to visible mold spots in the current residence. Our results suggested that early and lifetime exposures to household dampness indicators are risk factors for childhood asthma and rhinitis.

The quality of air outside and inside the home: associations with emotional and behavioural problem scores in early childhood

Background

This study explored the role of outdoor air pollution [nitrogen dioxide (NO₂) and sulphur dioxide (SO₂)] and indoor air quality (measured with damp or condensation and secondhand smoke exposures) at age 9 months in emotional, conduct and hyperactivity problems at age 3 years.

Method

Data from 11,625 Millennium Cohort Study children living in England and Wales were modelled using multilevel regression.

Results

After adjusting for a host of confounders, having a damp or condensation problem at home was related to both emotional and conduct problems. Secondhand smoke exposure was associated with all three problem types. Associations with outdoor air pollution were less consistent.

Conclusions

Exposures to damp or condensation and secondhand smoke in the home are likely to be risk factors for child emotional and behavioural problems. Parents should continue to be educated about the dangers of exposing their children to poor air quality at home.

Housing and health: new evidence using biomarker data

Background

The link between housing and health is well established and long-standing, however much of the evidence relies on self-reported health measures. While these are useful, the availability of biomarker data allows us to add to this evidence using objective indicators of health.

Methods

In this paper, we use C-reactive protein (CRP), a biomarker associated with infection and stress, alongside information relating to housing details, demographic characteristics and health behaviours taken from the UK Household Longitudinal Study. Hierarchical linear regression models estimate CRP for individual housing characteristics, and all available housing characteristics, controlling for confounders.

Results

Results indicate that housing tenure, type, cost burden and desire to stay in current home are associated with CRP. Private renters have significantly higher (worse) CRP than owners with a mortgage. In terms of housing type, respondents living in detached homes had lower CRP than those in semidetached or terraced houses, or those living in flats. Housing cost burden is associated with lower CRP, although further analysis indicates that this is the case only for low-income renters. Desire to stay in current home is significantly associated with higher CRP.

Conclusions

A number of housing characteristics were associated with CRP. These results further support an important role for housing in health.

Surface and passive/active air mould sampling: A testing exercise in a North London housing estate

Despite indoor mould being one of the most common problems in residential properties in the UK, there are not any widely accepted methodologies for its measurement. This paper focusses on this problem of measurement and reports on the findings from a rigorous testing scheme carried out to quantify air and surface mould concentrations and particle counts within 71 rooms from 64 properties in North London, some with and some without visible mould. The aim was to investigate the potential of passive and active air sampling strategies (sampling from still and actively mixed air, respectively) to explain visible mould, and understand how home/room characteristics correlate with the obtained readings. Airborne mould levels were quantified using an Andersen sampler (passively and actively), as well as by a chemical method based on the quantification of the N-acetylhexosaminidase (NAHA) activity (actively), which was also used to quantify surface mould. The mould levels were then correlated against physical characteristics of the tested homes/rooms, collected by means of survey sheets developed as part of this study. The findings did not reveal any independent variable governing all or most of the response variables, but a complex analysis suggested that whether it is a house or a flat could depict mould levels in the air and on the surfaces. It was also shown that a robust testing protocol should combine air and surface based methods, and an active air sampling strategy leads to a more accurate appraisal of airborne mould levels. Finally, the results showed that while there is some correlation between visible mould (and other moisture induced problems such as condensation) and measured air mould concentrations, lack of visible mould within a room does not necessarily mean low air mould concentrations, and thus one should not rely solely on visual inspection.

Flooding: what is the impact on pregnancy and child health?

Floods are the most common type of natural disaster in both developed and developing countries and have led to extensive morbidity and mortality throughout the world. Worldwide, over the past 30 years, flooding has claimed the lives of more than 200,000 people and affected more than 2.8 billion others. The impact of flooding on health varies among populations and depends primarily on vulnerability and the kind of event experienced. It severely disrupts livelihoods and has a significant impact on the health of pregnant women and children. In addition, it may exacerbate a range of negative psychological and physiological child and reproductive health outcomes. Awareness-raising, education, and the issuing of warnings appear to be key initiatives to mitigate or prevent flood morbidity and mortality, especially among people living in low- and middle-income countries. Agencies responding to emergencies also need to be more cognisant of the dangers, specifically those engaged in healthcare, nutrition, and water safety programmes.

Effects of Mycotoxins on Neuropsychiatric Symptoms and Immune Processes

PURPOSE

The effects of air pollutants have been receiving increased attention both clinically and in the media. One such pollutant is mold, fungal growth in the form of multicellular filaments known as hyphae. The growth of molds is omnipresent not only in outdoor settings but also in indoor environments containing excessive amounts of moisture.

METHODS

PubMed was searched for relevant articles using terms such as mold, mycotoxins, fungi, immunity, inflammation, neurodevelopment, cognition, Alzheimer's, and autism.

FINDINGS

Exposure to molds is most commonly associated with allergies and asthma. However, it is now thought to be associated with many complex health problems, since some molds, especially Trichoderma, Fusarium and Stachybotrys spp, produce mycotoxins that are absorbed from the skin, airways, and intestinal lining. People exposed to molds and mycotoxins present with symptoms affecting multiple organs, including the lungs, musculoskeletal system, as well as the central and peripheral nervous systems. Furthermore, evidence has recently implicated exposure to mycotoxins in the pathogenesis of autism spectrum disorder. The effects of mycotoxins can be mediated via different pathways that include the secretion of pro-inflammatory cytokines, especially from mast cells.

IMPLICATIONS

The information reviewed indicates that exposure to mold and mycotoxins can affect the nervous system, directly or through immune cell activation, thus contributing to neurodevelopmental disorders such as autism spectrum disorder.

The health impacts of energy performance investments in low-income areas: a mixed-methods approach

Background

Cold homes and fuel poverty contribute to health inequalities in ways that could be addressed through energy efficiency interventions.

Objectives

To determine the health and psychosocial impacts of energy performance investments in low-income areas, particularly hospital admissions for cardiorespiratory conditions, prevalence of respiratory symptoms and mental health status, hydrothermal conditions and household energy use, psychosocial outcomes, cost consequences to the health system and the cost utility of these investments.

Design

A mixed-methods study comprising data linkage (25,908 individuals living in 4968 intervention homes), a field study with a controlled pre-/post-test design (intervention,n = 418; control,n = 418), a controlled multilevel interrupted time series analysis of internal hydrothermal conditions (intervention,n = 48; control,n = 40) and a health economic assessment.

Setting

Low-income areas across Wales.

Participants

Residents who received energy efficiency measures through the intervention programme and matched control groups.

Main outcome measures

Primary outcomes – emergency hospital admissions for cardiorespiratory conditions, self-reported respiratory symptoms, mental health status, indoor air temperature and indoor relative humidity. Secondary outcomes – emergency hospital admissions for chronic obstructive pulmonary disease-related cardiorespiratory conditions, excess winter admissions, health-related quality of life, subjective well-being, self-reported fuel poverty, financial stress and difficulties, food security, social interaction, thermal satisfaction and self-reported housing conditions.

Methods

Anonymously linked individual health records for emergency hospital admissions were analysed using mixed multilevel linear models. A quasi-experimental controlled field study used a multilevel repeated measures approach. Controlled multilevel interrupted time series analyses were conducted to estimate changes in internal hydrothermal conditions following the intervention. The economic evaluation comprised cost–consequence and cost–utility analyses.

Data sources

The Patient Episode Database for Wales 2005–14, intervention records from 28 local authorities and housing associations, and scheme managers who delivered the programme.

Results

The study found no evidence of changes in physical health. However, there were improvements in subjective well-being and a number of psychosocial outcomes. The household monitoring study found that the intervention raised indoor temperature and helped reduce energy use. No evidence was found of substantial increases in indoor humidity levels. The health economic assessment found no explicit cost reductions to the health service as a result of non-significant changes in emergency admissions for cardiorespiratory conditions.

Limitations

This was a non-randomised intervention study with household monitoring and field studies that relied on self-response. Data linkage focused on emergency admissions only.

Conclusion

Although there was no evidence that energy performance investments provide physical health benefits or reduce health service usage, there was evidence that they improve social and economic conditions that are conducive to better health and improved subjective well-being. The intervention has been successful in reducing energy use and improving the living conditions of households in low-income areas. The lack of association of emergency hospital admissions with energy performance investments means that we were unable to evidence cost saving to health-service providers.

Future work

Our research suggests the importance of incorporating evaluations with follow-up into intervention research from the start.

Funding

The National Institute for Health Research Public Health Research programme.

Housing materials as predictors of under-five mortality in Nigeria: evidence from 2013 demographic and health survey

BACKGROUND

Nigeria is among countries with high Under-Five Mortality (U5M) rates worldwide. Both maternal and childhood factors have been linked to U5M in the country. However, despite the growing global recognition of the association between housing and quality of life, the role of housing materials as predictors of U5M remain largely unexplored in Nigeria. This study, therefore, investigated the relationship between housing materials and U5M in Nigeria.

METHODS

The study utilised the 2013 Nigeria Demographic and Health Survey data. A representative sample of 40,680 households was selected for the survey. The sample included 18,516 women of reproductive age who had given birth in the past 5 years prior the survey; with attention on the survival status of the index child (the most recent delivery). Data were analysed using descriptive statistics, Chi-square, Cox-proportional hazard and Brass 2-parameter models (α = 0.05).

RESULTS

The hazard ratio of U5M was 1.46 (C.I = 1.02-1.47, p < 0.001) and 1.23 (C.I = 1.24-1.71, p < 0.001) higher among children who lived in houses built with inadequate and moderate housing materials respectively than those in good housing materials. Under-five deaths show a downward trend (slope = -0.4871) relative to the housing materials assessment score. The refined U5M rate was 143.5, 127.0 and 90.8 per 1000 live birth among women who live in houses built with inadequate, moderate and adequate housing materials respectively. Other predictors of U5M were; the size of the child at birth, preceding birth interval, prenatal care provider, residence and education. Under-five death reduces with increasing maternal level of; education, wealth quintile, media exposure and housing material type and mostly experienced by Muslim women (6.0%), rural women (6.5%) and women residence in the North-West geopolitical zones (6.9%).

CONCLUSIONS

Living in houses built with poor housing materials promoted U5M in Nigeria. Provision of sustainable housing by the government and the maintenance of existing housing stock to healthful conditions will play a significant role in reducing the burden of U5M in Nigeria.

Rapid detection and identification of Stachybotrys and Chaetomium species using tissue PCR analysis

Indoor fungi are a worldwide problem causing negative health effects for infected building's occupants and even deterioration of building structures. Different fungal species affect buildings and their inhabitants differently. Therefore, rapid and accurate identification of fungi to the species level is essential for health risk assessment and building remediation. This study focuses on molecular identification of two common indoor fungal genera: Stachybotrys and Chaetomium. This study proposes two new DNA barcode candidates for Stachybotrys and Chaetomium: the gene encoding mitogen activated protein kinase (hogA) and the intergenic region between histone 3 and histone 4 (h3-h4) as well as it introduces a rapid - 3.5h - protocol for direct Stachybotrys and Chaetomium species identification, which bypasses culture cultivation, DNA extraction and DNA sequencing.

Indoor air quality in green-renovated vs. non-green low-income homes of children living in a temperate region of US (Ohio)

Green eco-friendly housing includes approaches to reduce indoor air pollutant sources and to increase energy efficiency. Although sealing/tightening buildings can save energy and reduce the penetration of outdoor pollutants, an adverse outcome can be increased buildup of pollutants with indoor sources. The objective of this study was to determine the differences in the indoor air quality (IAQ) between green and non-green homes in low-income housing complexes. In one housing complex, apartments were renovated using green principles (n=28). Home visits were conducted immediately after the renovation, and subsequently at 6 months and at 12 months following the renovation. Of these homes, eight homes had pre-renovation home visits; this allowed pre- and post-renovation comparisons within the same homes. Parallel visits were conducted in non-green (control) apartments (n=14) in a nearby low-income housing complex. The IAQ assessments included PM2.5, black carbon, ultrafine particles, sulfur, total volatile organic compounds (VOCs), formaldehyde, and air exchange rate. Data were analyzed using linear mixed-effects models. None of the indoor pollutant concentrations were significantly different between green and non-green homes. However, we found differences when comparing the concentrations before and after renovation. Measured immediately after renovation, indoor black carbon concentrations were significantly lower averaging 682 ng/m(3) in post-renovation vs. 2364 ng/m(3) in pre-renovation home visits (p=0.01). In contrast, formaldehyde concentrations were significantly higher in post-renovated (0.03 ppm) than in pre-renovated homes (0.01 ppm) (p=0.004). Questionnaire data showed that opening of windows occurred less frequently in homes immediately post-renovation compared to pre-renovation; this factor likely affected the levels of indoor black carbon (from outdoor sources) and formaldehyde (from indoor sources) more than the renovation status itself. To reduce IAQ problems and potentially improve health, careful selection of indoor building materials and ensuring sufficient ventilation are important for green building designs.

Procedures to Assist Health Care Providers to Determine When Home Assessments for Potential Mold Exposure Are Warranted

Drawing evidence from epidemiology and exposure assessment studies and recommendations from expert practice, we describe a process to guide health care providers helping their patients who present with symptoms that might be associated with living in damp housing. We present the procedures in the form of a guided 2-part interview. The first part has 5 questions that triage the patient toward a more detailed questionnaire that reflects features of housing conditions known to be reliably associated with exposures to mold and dampness contaminants. We chose the questions based on the conditions associated with moisture problems in homes across the United States and Canada. The goal is to facilitate the clinician's effort to help patients reduce exposure to environmental triggers that elicit symptoms to better manage their disease.

The Black Yeast Exophiala dermatitidis and Other Selected Opportunistic Human Fungal Pathogens Spread from Dishwashers to Kitchens

We investigated the diversity and distribution of fungi in nine different sites inside 30 residential dishwashers. In total, 503 fungal strains were isolated, which belong to 10 genera and 84 species. Irrespective of the sampled site, 83% of the dishwashers were positive for fungi. The most frequent opportunistic pathogenic species were Exophiala dermatitidis, Candida parapsilosis sensu stricto, Exophiala phaeomuriformis, Fusarium dimerum, and the Saprochaete/Magnusiomyces clade. The black yeast E. dermatitidis was detected in 47% of the dishwashers, primarily at the dishwasher rubber seals, at up to 10⁶ CFU/cm²; the other fungi detected were in the range of 10² to 10⁵ CFU/cm². The other most heavily contaminated dishwasher sites were side nozzles, doors and drains. Only F. dimerum was isolated from washed dishes, while dishwasher waste water contained E. dermatitidis, Exophiala oligosperma and Sarocladium killiense. Plumbing systems supplying water to household appliances represent the most probable route for contamination of dishwashers, as the fungi that represented the core dishwasher mycobiota were also detected in the tap water. Hot aerosols from dishwashers contained the human opportunistic yeast C. parapsilosis, Rhodotorula mucilaginosa and E. dermatitidis (as well as common air-borne genera such as Aspergillus, Penicillium, Trichoderma and Cladosporium). Comparison of fungal contamination of kitchens without and with dishwashers revealed that virtually all were contaminated with fungi. In both cases, the most contaminated sites were the kitchen drain and the dish drying rack. The most important difference was higher prevalence of black yeasts (E. dermatitidis in particular) in kitchens with dishwashers. In kitchens without dishwashers, C. parapsilosis strongly prevailed with negligible occurrence of E. dermatitidis. F. dimerum was isolated only from kitchens with dishwashers, while Saprochaete/Magnusiomyces isolates were only found within dishwashers. We conclude that dishwashers represent a reservoir of enriched opportunistic pathogenic species that can spread from the dishwasher into the indoor biome.

Poor housing conditions in association with child health in a disadvantaged immigrant population: a cross-sectional study in Rosengård, Malmö, Sweden

OBJECTIVES

To describe the home environment in terms of housing conditions and their association with child health in a disadvantaged immigrant population.

DESIGN

A cross-sectional observational study.

SETTING

Enrolment took place during 2010-2011 in Rosengård, Malmö, Sweden.

PARTICIPANTS

Children aged 0-13 years in 2 study neighbourhoods were recruited from local health records and from schools. 359 children participated, with a participation rate of 40%. Data on health, lifestyle and apartment characteristics from questionnaire-led interviews with the mothers of the children were obtained together with data from home inspections carried out by trained health communicators.

OUTCOME MEASURES

Logistic regression analysis was used to estimate ORs for various health outcomes, adjusted for demographic information and lifestyle factors.

RESULTS

The housing conditions were very poor, especially in one of the study neighbourhoods where 67% of the apartments had been sanitised of cockroaches, 27% were infested with cockroaches and 40% had a visible mould. The association between housing conditions and health was mostly inconclusive, but there were statistically significant associations between current asthma and dampness (OR=4.1, 95% CI 1.7 to 9.9), between asthma medication and dampness (OR=2.8, 95% CI 1.2 to 6.4), and between mould and headache (OR=4.2, 95% CI 1.2 to 14.8). The presence of cockroaches was associated with emergency care visits, with colds, with headache and with difficulty falling asleep, and worse general health was associated with mould and presence of cockroaches.

CONCLUSIONS

The associations between dampness and asthma, and the association between mould and headache, are in line with current knowledge. The presence of cockroaches seemed to be associated with various outcomes, including those related to mental well-being, which is less described in the literature. The results of the present study are hypothesis generating and provide strong incentives for future studies in this study population.

Can housing improvements cure or prevent the onset of health conditions over time in deprived areas?

BACKGROUND

There is a need for more evidence linking particular housing improvements to changes in specific health conditions. Research often looks at generic works over short periods.

METHODS

We use a longitudinal sample (n = 1933) with a survey interval of 2-5 years. Multivariate logistic regression is used to calculate the odds ratios of developing or recovering from six health conditions according to receipt of four types of housing improvements.

RESULTS

Receipt of fabric works was associated with higher likelihood of recovery from mental health problems and circulatory conditions. Receipt of central heating was also associated with higher likelihood of recovery form circulatory conditions. No evidence was found for the preventative effects of housing improvements.

CONCLUSIONS

Health gain from housing improvements appears most likely when targeted at those in greatest health need. The health impacts of area-wide, non-targeted housing improvements are less clear in our study.

Fuel poverty as a major determinant of perceived health: the case of France

OBJECTIVES

The number of households in fuel poverty is growing. Individuals increasingly struggle to heat their homes, and therefore, a growing number of individuals are exposed to low temperatures, which can affect their health. This study sought to determine the link between a subjective measure of fuel poverty (self-reported feeling cold) and self-reported health. The impact of other particular individual and environmental features on self-reported health were also analysed.

STUDY DESIGN

Econometric analysis.

METHODS

The study method uses self-reported perception of thermal discomfort (self-reported feeling cold) as a proxy for fuel poverty. The French database of the Healthcare and Insurance survey carried by the Institute for Research and Information on Health Economics (IRDES) was used to estimate a dichotomous probit model.

RESULTS

The estimation allows us to infer a negative impact of fuel poverty on self-reported health. Thus, a person in fuel poverty is 2.36 percentage points more likely to report poor or fair health status than a person who is not in fuel poverty.

CONCLUSION

It may be appropriate to reduce the impacts of fuel poverty to provide support for the most vulnerable categories of individuals with respect to the health impacts of fuel poverty and cold homes, e.g., chronic patients who experience difficulty heating their homes.

Homes of low-income minority families with asthmatic children have increased condition issues

The home is increasingly associated with asthma. It acts both as a reservoir of asthma triggers and as a refuge from seasonal outdoor allergen exposure. Racial/ethnic minority families with low incomes tend to reside in neighborhoods with low housing quality. These families also have higher rates of asthma. This study explores the hypothesis that black and Latino urban households with asthmatic children experienced more home mechanical, structural condition-related areas of concern than white households with asthmatic children. Participant families (n = 140) took part in the Kansas City Safe and Healthy Homes Program, had at least one asthmatic child, and met income qualifications of no more than 80% of local median income; many were below 50%. Families self-identified their race. Homes were assessed by environmental health professionals using a standard set of criteria and a specific set of on-site and laboratory sampling and analyses. Homes were given a score for areas of concern between 0 (best) and 53 (worst). The study population self-identified as black (46%), non-Latino white (26%), Latino (14.3%), and other (12.9%). Mean number of areas of concern were 18.7 in Latino homes, 17.8 in black homes, 13.3 in other homes, and 13.2 in white homes. Latino and black homes had significantly more areas of concern. White families were also more likely to be in the upper portion of the income. In this set of 140 low-income homes with an asthmatic child, households of minority individuals had more areas of condition concerns and generally lower income than other families.

Home dampness, childhood asthma, hay fever, and airway symptoms in Shanghai, China: associations, dose-response relationships, and lifestyle's influences

Numerous studies of associations between dampness and respiratory diseases have been conducted, but their implications remain inconclusive. In this study of 13,335 parent-reported questionnaires (response rate: 85.3%), we analyzed associations between home dampness and asthma and related symptoms in 4- to 6-year-old children in a cross-sectional study of Shanghai. Indicators of home dampness were strongly and significantly associated with dry cough, wheeze, and rhinitis symptoms. In the current residence, children with visible mold spots (VMS) exposure had 32% higher risk of asthma (adjusted OR, 95% CI: 1.32, 1.07-1.64); damp clothing and/or bedding (frequently) was strongly associated with dry cough (1.78, 1.37-2.30); condensation on windows was strongly associated with hay fever (1.60, 1.27-2.01). In the early-life residence, VMS or damp stains (frequently) were strongly associated with dry cough (2.20, 1.55-3.11) and rhinitis ever (1.57, 1.11-2.21). Associations between dampness and diseases among children with or without family history of atopy were similar. The total number of dampness indicators had strong dose-response relationships with investigated health outcomes. Actions, including opening windows of the child's room at night and cleaning the child's room frequently, could potentially mitigate 25% of home VMS, thereby preventing more than 1.5% of attributable risk of the studied symptoms.

Current asthma in schoolchildren is related to fungal spores in classrooms

BACKGROUND

The presence of visible mold in households is associated with asthma. However, the role of "classroom fungus" in the development of childhood asthma, as well as the fungal species that may lead to asthma, remains controversial. This nationwide school survey was conducted to investigate the correlation between fungal spores in classrooms and asthma in schoolchildren.

METHODS

From April to May 2011, a cross-sectional survey was conducted to assess allergic/asthmatic conditions in schoolchildren aged 6 to 15 years old in 44 schools across Taiwan. Personal histories and current asthmatic conditions were collected using a modified International Study of Asthma and Allergies in Childhood questionnaire. Fungal spores in classroom were collected using a Burkard Personal Air Sampler and counted under light microscopy. Three-level hierarchical modeling was used to determine the complex correlation between fungal spores in classrooms and childhood asthma.

RESULTS

The survey was completed by 6,346 out of 7,154 parents (88.7%). The prevalences of physician-diagnosed asthma, current asthma, and asthma with symptoms reduced on holidays or weekends (ASROH) were 11.7%, 7.5%, and 3.1%, respectively. The geometric mean spore concentrations of total fungi, Aspergillus/Penicillium, and basidiospores were 2,181, 49, and 318 spores/m3. Aspergillus/Penicillium and basidiospores were significantly correlated with current asthma and ASROH after adjusting for personal and school factors. Of those with current asthma, 41% reported relief of symptoms during weekends.

CONCLUSIONS

Classroom Aspergillus/Penicillium and basidiospores are significantly associated with childhood asthma and ASROH. Government health policy should explore environmental interventions for the elimination of fungal spores in classrooms to reduce the prevalence of childhood asthma.

[Impact on the indoor environment of allergic children of the medical counselor on indoor environment, after two successive visits at 6 months interval]

BACKGROUND

The aim of this retrospective study was to assess the impact of a medical indoor environment counselor (MIEC) on the allergic child's indoor home environment, as well as the real-life experience of patients' families.

METHODS

We enrolled 50 children (age, 4-18 years) with allergic respiratory illness (96 % asthmatics) from March 2011 to January 2012. During the first visit, the CMEI gave advice according to the results of the assessment. Home environmental exposures were assessed 6 months later. A satisfaction questionnaire was completed by the parents.

RESULTS

We found a significant decrease in the presence of house dust mites (P = 0.0047), humidity, and molds (P = 0.0047) as well as volatile organic compounds (P = 0.0047). Smoking habits were not significantly changed (P = 0.083), nor was the presence of domestic pets (P = 0.3173). Over 74 % of the families were very satisfied with the CMEI's intervention.

DISCUSSION

According to de Blay's study, a home visit by the MEIC increased compliance with mite reduction. The intervention to advise parents of asthmatic children on the risks of passive smoking was ineffective in reducing their children's exposure to environmental tobacco smoke. The advice given by the MEIC was better understood by the patients than that expressed by the medical teams.

CONCLUSION

A targeted home-based environmental intervention increased the compliance to mite, humidity, and mold reduction. The role of the CMEI will undoubtedly develop: follow-up studies are necessary to justify their activity (cost-efficacy ratio of their intervention).

A systematic review on the development of asthma and allergic diseases in relation to international immigration: the leading role of the environment confirmed

BACKGROUND

The prevalence of asthma and allergic diseases is rising worldwide. Evidence on potential causal pathways of asthma and allergies is growing, but findings have been contradictory, particularly on the interplay between allergic diseases and understudied social determinants of health like migration status. This review aimed at providing evidence for the association between migration status and asthma and allergies, and to explore the mechanisms between migration status and the development of asthma and allergies.

METHODS AND FINDINGS

Systematic review on asthma and allergies and immigration status in accordance with the guidelines set by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement. The pooled odds ratio (OR) of the prevalence of asthma in immigrants compared to the host population was 0.60 (95% CI 0.45-0.84), and the pooled OR for allergies was 1.01 (95% CI 0.62-1.69). The pooled OR for the prevalence of asthma in first generation versus second generation immigrants was 0.37 (95% CI 0.25-0.58). Comparisons between populations in their countries of origin and those that emigrated vary depending on their level of development; more developed countries show higher rates of asthma and allergies.

CONCLUSIONS

Our findings suggest a strong influence of the environment on the development of asthma and allergic diseases throughout the life course. The prevalence of asthma is generally higher in second generation than first generation immigrants. With length of residence in the host country the prevalence of asthma and allergic diseases increases steadily. These findings are consistent across study populations, host countries, and children as well as adults. Differences have been found to be significant when tested in a linear model, as well as when comparing between early and later age of migration, and between shorter and longer time of residence.

The causal effect of family income on child health in the U.K

Recent studies examining the effect of family income on child health have been unable to account for the endogeneity of income. Using data from a British cohort study, we address this gap by exploiting exogenous variation in local labour market characteristics to instrument for family income. We estimate the causal effect of family income on different measures of child health and explore the role of potential transmission mechanisms. We find that income has a very small but significant causal effect on subjective child health and no significant effect on chronic health conditions, apart from respiratory illnesses. Using the panel structure, we show that the timing of income does not matter for young children. Moreover, our results provide further evidence that parental health does not drive a spurious relationship between family income and child health. Our study implies that financial transfers are unlikely to deliver substantial improvements in child health.

Effect of relative humidity on the aerosolization and total inflammatory potential of fungal particles from dust-inoculated gypsum boards

The aim of this study was to investigate the effect of relative humidity (RH) on the aerosolization and total inflammatory potential (TIP) of microbial particles released from gypsum boards inoculated with dust samples from homes. After microbial colonization, the gypsum boards were incubated at either high or low RH. The aerosolized particles (0.54-19.8 μm), culturable fungi, β-glucan and the TIP of the aerosolized particles were quantified. Despite the colonization of several fungal groups, Penicillium dominated the aerosolized fraction. Higher emission rates of particles and culturable fungi were found from low RH compared with high RH in both the inhalable and particulate matter <1 μm (PM1 ) fractions, and the TIP was accordingly higher. However, for the aerosolized fractions, the TIP or concentration β-glucan relative to the number of fungi or particles present was higher from high RH compared with low RH. Despite the low number of culturable fungi in PM1 , this fraction showed a high TIP, and the concentration of β-glucan correlated strongly with the TIP of this fraction. The individual particles of the aerosolized PM1 fraction were more inflammatory than the larger particles of the inhalable fraction, and β-glucan may be an important contributor to the inflammatory potential of the aerosolized particles.

Phthalate metabolites in urine and asthma, allergic rhinoconjunctivitis and atopic dermatitis in preschool children

Phthalate esters are among the most ubiquitous of indoor pollutants and have been associated with various adverse health effects. In the present study we assessed the cross-sectional association between eight different phthalate metabolites in urine and allergic disease in young children. As part of the Danish Indoor Environment and Children's Health study, urine samples were collected from 440 children aged 3-5 years, of whom 222 were healthy controls, 68 were clinically diagnosed with asthma, 76 with rhinoconjunctivitis and 81 with atopic dermatitis (disease subgroups are not mutually exclusive; some children had more than one disease). There were no statistically significant differences in the urine concentrations of phthalate metabolites between cases and healthy controls with the exception of MnBP and MECPP, which were higher in healthy controls compared with the asthma case group. In the crude analysis MnBP and MiBP were negatively associated with asthma. In the analysis adjusted for multiple factors, only a weak positive association between MEP in urine and atopic dermatitis was found; there were no positive associations between any phthalate metabolites in urine and either asthma or rhinoconjunctivitis. These findings appear to contradict earlier studies. Differences may be due to higher exposures to certain phthalates (e.g., BBzP) via non-dietary pathways in earlier studies, phthalates serving as surrogates for an agent associated with asthma (e.g., PVC flooring) in previous studies but not the present study or altered cleaning habits and the use of "allergy friendly" products by parents of children with allergic disease in the current study in contrast to studies conducted earlier.

Promoting health and advancing development through improved housing in low-income settings

There is major untapped potential to improve health in low-income communities through improved housing design, fittings, materials and construction. Adverse effects on health from inadequate housing can occur through a range of mechanisms, both direct and indirect, including as a result of extreme weather, household air pollution, injuries or burns, the ingress of disease vectors and lack of clean water and sanitation. Collaborative action between public health professionals and those involved in developing formal and informal housing could advance both health and development by addressing risk factors for a range of adverse health outcomes. Potential trade-offs between design features which may reduce the risk of some adverse outcomes whilst increasing the risk of others must be explicitly considered.

Housing improvements for health and associated socio-economic outcomes

BACKGROUND

The well established links between poor housing and poor health indicate that housing improvement may be an important mechanism through which public investment can lead to health improvement. Intervention studies which have assessed the health impacts of housing improvements are an important data resource to test assumptions about the potential for health improvement. Evaluations may not detect long term health impacts due to limited follow-up periods. Impacts on socio-economic determinants of health may be a valuable proxy indication of the potential for longer term health impacts.

OBJECTIVES

To assess the health and social impacts on residents following improvements to the physical fabric of housing.

SEARCH METHODS

Twenty seven academic and grey literature bibliographic databases were searched for housing intervention studies from 1887 to July 2012 (ASSIA; Avery Index; CAB Abstracts; The Campbell Library; CINAHL; The Cochrane Library; COPAC; DH-DATA: Health Admin; EMBASE; Geobase; Global Health; IBSS; ICONDA; MEDLINE; MEDLINE In-Process & Other Non-Indexed Citations; NTIS; PAIS; PLANEX; PsycINFO; RIBA; SCIE; Sociological Abstracts; Social Science Citations Index; Science Citations Index expanded; SIGLE; SPECTR). Twelve Scandinavian grey literature and policy databases (Libris; SveMed+; Libris uppsök; DIVA; Artikelsök; NORART; DEFF; AKF; DSI; SBI; Statens Institut for Folkesundhed; Social.dk) and 23 relevant websites were searched. In addition, a request to topic experts was issued for details of relevant studies. Searches were not restricted by language or publication status.

SELECTION CRITERIA

Studies which assessed change in any health outcome following housing improvement were included. This included experimental studies and uncontrolled studies. Cross-sectional studies were excluded as correlations are not able to shed light on changes in outcomes. Studies reporting only socio-economic outcomes or indirect measures of health, such as health service use, were excluded. All housing improvements which involved a physical improvement to the fabric of the house were included. Excluded interventions were improvements to mobile homes; modifications for mobility or medical reasons; air quality; lead removal; radon exposure reduction; allergen reduction or removal; and furniture or equipment. Where an improvement included one of these in addition to an included intervention the study was included in the review. Studies were not excluded on the basis of date, location, or language.

DATA COLLECTION AND ANALYSIS

Studies were independently screened and critically appraised by two review authors. Study quality was assessed using the risk of bias tool and the Hamilton tool to accommodate non-experimental and uncontrolled studies. Health and socio-economic impact data were extracted by one review author and checked by a second review author. Studies were grouped according to broad intervention categories, date, and context before synthesis. Where possible, standardized effect estimates were calculated and statistically pooled. Where meta-analysis was not appropriate the data were tabulated and synthesized narratively following a cross-study examination of reported impacts and study characteristics. Qualitative data were summarized using a logic model to map reported impacts and links to health impacts; quantitative data were incorporated into the model.

MAIN RESULTS

Thirty-nine studies which reported quantitative or qualitative data, or both, were included in the review. Thirty-three quantitative studies were identified. This included five randomised controlled trials (RCTs) and 10 non-experimental studies of warmth improvements, 12 non-experimental studies of rehousing or retrofitting, three non-experimental studies of provision of basic improvements in low or mIddle Income countries (LMIC), and three non-experimental historical studies of rehousing from slums. Fourteen quantitative studies (42.4%) were assessed to be poor quality and were not included in the synthesis. Twelve studies reporting qualitative data were identified. These were studies of warmth improvements (n = 7) and rehousing (n = 5). Three qualitative studies were excluded from the synthesis due to lack of clarity of methods. Six of the included qualitative studies also reported quantitative data which was included in the review.Very little quantitative synthesis was possible as the data were not amenable to meta-analysis. This was largely due to extreme heterogeneity both methodologically as well as because of variations in the intervention, samples, context, and outcome; these variations remained even following grouping of interventions and outcomes. In addition, few studies reported data that were amenable to calculation of standardized effect sizes. The data were synthesised narratively.Data from studies of warmth and energy efficiency interventions suggested that improvements in general health, respiratory health, and mental health are possible. Studies which targeted those with inadequate warmth and existing chronic respiratory disease were most likely to report health improvement. Impacts following housing-led neighbourhood renewal were less clear; these interventions targeted areas rather than individual households in most need. Two poorer quality LMIC studies reported unclear or small health improvements. One better quality study of rehousing from slums (pre-1960) reported some improvement in mental health. There were few reports of adverse health impacts following housing improvement. A small number of studies gathered data on social and socio-economic impacts associated with housing improvement. Warmth improvements were associated with increased usable space, increased privacy, and improved social relationships; absences from work or school due to illness were also reduced.Very few studies reported differential impacts relevant to equity issues, and what data were reported were not amenable to synthesis.

AUTHORS' CONCLUSIONS

Housing investment which improves thermal comfort in the home can lead to health improvements, especially where the improvements are targeted at those with inadequate warmth and those with chronic respiratory disease. The health impacts of programmes which deliver improvements across areas and do not target according to levels of individual need were less clear, but reported impacts at an area level may conceal health improvements for those with the greatest potential to benefit. Best available evidence indicates that housing which is an appropriate size for the householders and is affordable to heat is linked to improved health and may promote improved social relationships within and beyond the household. In addition, there is some suggestion that provision of adequate, affordable warmth may reduce absences from school or work.While many of the interventions were targeted at low income groups, a near absence of reporting differential impacts prevented analysis of the potential for housing improvement to impact on social and economic inequalities.

Airborne molds and bacteria, microbial volatile organic compounds (MVOC), plasticizers and formaldehyde in dwellings in three North European cities in relation to sick building syndrome (SBS)

There are few studies on associations between airborne microbial exposure, formaldehyde, plasticizers in dwellings and the symptoms compatible with the sick building syndrome (SBS). As a follow-up of the European Community Respiratory Health Survey (ECRHS II), indoor measurements were performed in homes in three North European cities. The aim was to examine whether volatile organic compounds of possible microbial origin (MVOCs), and airborne levels of bacteria, molds, formaldehyde, and two plasticizers in dwellings were associated with the prevalence of SBS, and to study associations between MVOCs and reports on dampness and mold. The study included homes from three centers included in ECRHS II. A total of 159 adults (57% females) participated (19% from Reykjavik, 40% from Uppsala, and 41% from Tartu). A random sample and additional homes with a history of dampness were included. Exposure measurements were performed in the 159 homes of the participants. MVOCs were analyzed by GCMS with selective ion monitoring (SIM). Symptoms were reported in a standardized questionnaire. Associations were analyzed by multiple logistic regression. In total 30.8% reported any SBS (20% mucosal, 10% general, and 8% dermal symptoms) and 41% of the homes had a history of dampness and molds There were positive associations between any SBS and levels of 2-pentanol (P=0.002), 2-hexanone (P=0.0002), 2-pentylfuran (P=0.009), 1-octen-3-ol (P=0.002), formaldehyde (P=0.05), and 2,2,4-trimethyl-1,3-pentanediol monoisobutyrate (Texanol) (P=0.05). 1-octen-3-ol (P=0.009) and 3-methylfuran (P=0.002) were associated with mucosal symptoms. In dwellings with dampness and molds, the levels of total bacteria (P=0.02), total mold (P=0.04), viable mold (P=0.02), 3-methylfuran (P=0.008) and ethyl-isobutyrate (P=0.02) were higher. In conclusion, some MVOCs like 1-octen-3-ol, formaldehyde and the plasticizer Texanol, may be a risk factor for sick building syndrome. Moreover, concentrations of airborne molds, bacteria and some other MVOCs were slightly higher in homes with reported dampness and mold.

Comparison of sampling methods for the assessment of indoor microbial exposure

Indoor microbial exposure has been related to allergy and respiratory disorders. However, the lack of standardized sampling methodology is problematic when investigating dose-response relationships between exposure and health effects. In this study, different sampling methods were compared regarding their assessment of microbial exposures, including culturable fungi and bacteria, endotoxin, as well as the total inflammatory potential (TIP) of dust samples from Danish homes. The Gesamtstaubprobenahme (GSP) filter sampler and BioSampler were used for sampling of airborne dust, whereas the dust fall collector (DFC), the electrostatic dust fall collector (EDC), and vacuum cleaner were used for sampling of settled dust. The GSP assessed significantly higher microbial levels than the BioSampler, yet measurements from both samplers correlated significantly. Considerably higher levels of fungi, endotoxin, and TIP were found in the EDC compared with the DFC, and regarding fungi, the EDC correlated more strongly and significantly with vacuumed dust than the DFC. Fungi in EDC and vacuum dust correlated most strongly with airborne dust, and in particular, the measurements from the EDC associated well with those from GSP. Settled dust from the EDC was most representative of airborne dust and may thus be considered as a surrogate for the assessment of indoor airborne microbial exposure.

PRACTICAL IMPLICATIONS

Significant discrepancies between sampling methods regarding indoor microbial exposures have been revealed. This study thus facilitates comparison between methods and may therefore be used as a frame of reference when studying the literature or when conducting further studies on indoor microbial exposure. Results also imply that the relatively simple EDC method for the collection of settled dust may be used as an alternative to otherwise tedious and time-consuming airborne dust sampling.

Seasonal variations of indoor microbial exposures and their relation to temperature, relative humidity, and air exchange rate

Indoor microbial exposure has been related to adverse pulmonary health effects. Exposure assessment is not standardized, and various factors may affect the measured exposure. The aim of this study was to investigate the seasonal variation of selected microbial exposures and their associations with temperature, relative humidity, and air exchange rates in Danish homes. Airborne inhalable dust was sampled in five Danish homes throughout the four seasons of 1 year (indoors, n = 127; outdoors, n = 37). Measurements included culturable fungi and bacteria, endotoxin, N-acetyl-beta-d-glucosaminidase, total inflammatory potential, particles (0.75 to 15 μm), temperature, relative humidity, and air exchange rates. Significant seasonal variation was found for all indoor microbial exposures, excluding endotoxin. Indoor fungi peaked in summer (median, 235 CFU/m(3)) and were lowest in winter (median, 26 CFU/m(3)). Indoor bacteria peaked in spring (median, 2,165 CFU/m(3)) and were lowest in summer (median, 240 CFU/m(3)). Concentrations of fungi were predominately higher outdoors than indoors, whereas bacteria, endotoxin, and inhalable dust concentrations were highest indoors. Bacteria and endotoxin correlated with the mass of inhalable dust and number of particles. Temperature and air exchange rates were positively associated with fungi and N-acetyl-beta-d-glucosaminidase and negatively with bacteria and the total inflammatory potential. Although temperature, relative humidity, and air exchange rates were significantly associated with several indoor microbial exposures, they could not fully explain the observed seasonal variations when tested in a mixed statistical model. In conclusion, the season significantly affects indoor microbial exposures, which are influenced by temperature, relative humidity, and air exchange rates.

Clinical significance of Alternaria alternata sensitization in patients with allergic rhinitis

PURPOSE

The aim of the study was to determine the epidemiologic profile of Alternaria alternata (AA)-sensitized patients with allergic rhinitis including coexistence of other atopic diseases, seasonal distribution of AA aeroallergens, age of onset of AA sensitization, and prevalence of sensitization to other allergens.

MATERIALS AND METHODS

History, clinical examination, and skin prick tests were performed in 623 patients with allergic rhinitis from central Greece. Patients' age, cosensitization, place of living, seasonal distribution, and concomitant symptoms were the variables used to discriminate between AA-sensitized and non-AA-sensitized patients. Significant predictor variables for AA sensitization were determined.

RESULTS

A alternata sensitization was associated with male sex, age younger than 18 years, living in new-built apartments in urban and semiurban areas by the sea, perennial distribution, and nonsmoking. A alternata-sensitized patients were affected more frequently by asthma than non-AA-sensitized patients. No significant differences were found in frequency of bronchitis, cough, conjunctivitis, urticaria, or eczema between patients sensitized or not to AA. Most (66.7%) of AA-sensitized patients were oligosensitized, 18.5% of patients were polysensitized, and 14.8% were monosensitized. Patients' age, cosensitization, place of living, and seasonal distribution were the significant predictor variables discriminating AA-sensitized from non-AA-sensitized patients. These variables correctly classified 79.7% of the patients. A alternata-sensitized patients were more frequently sensitized to grasses, cat epithelia, and flours-rye and less frequently sensitized to artemisia, Dermatophagoides pteronyssinus, D farinae, and chenopodium.

CONCLUSIONS

Patients meeting the aforementioned epidemiologic criteria should be preferentially offered skin prick tests for AA sensitization.

Cognitive function of 6-year old children exposed to mold-contaminated homes in early postnatal period. Prospective birth cohort study in Poland

In the last decade, the neurologic effects of various air pollutants have been the focus of increasing attention. The main purpose of this study was to assess the potential impact of early childhood exposure to indoor molds on the subsequent cognitive function of 6-year old children. The results of this study are based on the six-year follow-up of 277 babies born at term to mothers participating in a prospective cohort study in Krakow, Poland. The study participants are all non-smoking pregnant women who were free of chronic diseases such as diabetes and hypertension. The presence of visible mold patches on indoor walls was monitored at regular time intervals over gestation and after birth up to the age of five. The Wechsler Intelligence Scale for Children (WISC-R) was administered to children at age 6. The exposure effect of living in mold-contaminated homes on the IQ scores of children was adjusted for major confounders, known to be important for the cognitive development of children such as maternal education, the child's gender, breastfeeding practices in infancy, the presence of older siblings and the prenatal exposure to lead and environmental tobacco smoke (ETS). The adjusted IQ deficit attributed to longer exposures to indoor molds (>2 years) was significantly lower on the IQ scale (beta coeff.=-9.16, 95%CI: -15.21, -3.10) and tripled the risk of low IQ scoring (OR=3.53; 95%CI: 1.11-11.27) compared with references. While maternal education (beta coeff.=0.61, 95%CI: 0.05, 1.17) and breastfeeding (beta coeff.=4.0; 95%CI: 0.84, 7.17) showed a significant positive impact on cognitive function, prenatal ETS exposure (beta coeff.=-0.41; 95%CI: -0.79, -0.03) and the presence of older siblings (beta coefficient=-3.43; 95%CI: -5.67, -1.20) were associated with poorer cognitive function in children. In conclusion, the results of this study draw attention to the harmful effect of early postnatal exposure to indoor molds on children's cognitive development and provide additional evidence on the role of environmental determinants in human cognitive development.

Indoor environment and children's health: recent developments in chemical, biological, physical and social aspects

Much research is being carried out into indoor exposure to harmful agents. This review focused on the impact on children's health, taking a broad approach to the indoor environment and including chemical, microbial, physical and social aspects. Papers published from 2006 onwards were reviewed, with regards to scientific context. Most of publications dealt with chemical exposure. Apart from the ongoing issue of combustion by-products, most of these papers concerned semi volatile organic compounds (such as phthalates). These may be associated with neurotoxic, reprotoxic or respiratory effects and may, therefore, be of particular interest so far as children are concerned. In a lesser extent, volatile organic compounds (such as aldehydes) that have mainly respiratory effects are still studied. Assessing exposure to metals is still of concern, with increasing interest in bioaccessibility. Most of the papers on microbial exposure focused on respiratory tract infections, especially asthma linked to allergens and bio-aerosols. Physical exposure includes noise and electromagnetic fields, and articles dealt with the auditory and non auditory effects of noise. Articles on radiofrequency electromagnetic fields mainly concerned questions about non-thermal effects and papers on extremely low-frequency magnetic fields focused on the characterization of exposure. The impact of the indoor environment on children's health cannot be assessed merely by considering the effect of these different types of exposure: this review highlights new findings and also discusses the interactions between agents in indoor environments and also with social aspects.

The influence of water activity and temperature on germination, growth and sporulation of Stachybotrys chartarum strains

The objectives were to determine the influence of water activity (a(w), 0.997-0.92) and temperature (10-37°C) and their interactions on conidial germination, mycelial growth and sporulation of two strains of Stachybotrys chartarum in vitro on a potato dextrose medium. Studies were carried out by modifying the medium with glycerol and either spread plating with conidia to evaluate germination and germ tube extension or centrally inoculating treatment media for measuring mycelial growth rates and harvesting whole colonies for determining sporulation. Overall, germination of conidia was significantly influenced by a(w) and temperature and was fastest at 0.997-0.98 a(w) between 15 and 30°C with complete germination within 24 h. Germ tube extension was found to be most rapid at similar a(w) levels and 25-30°C. Mycelial growth rates of both strains were optimal at 0.997 a(w) between 25 and 30°C, with very little growth at 37°C. Sporulation was optimum at 30°C at 0.997 a(w). However, under drier conditions, this was optimum at 25°C. This shows that there are differences in the ranges of a(w) x temperature for germination and growth and for sporulation. This may help in understanding the role of this fungal species in damp buildings and conditions under which immune-compromised patients may be at risk when exposed to such contaminants in the indoor air environment.

Determination of Aspergillus fumigatus allergen 1 in poultry farms using the enzyme immunoassay

Poultry farms contain high levels of allergenic fungi, and Aspergillus spp. is the most common genus of moulds. Aspergillus fumigatus antigens are responsible for the development of several respiratory diseases including asthma. The aim of this study was to measure the mass fraction of Asp f 1, a major allergen of Asperillus fumigatus in 37 indoor dust samples collected from four poultry farms in a rural area of the Zagreb County (Croatia) using the enzyme-linked immunosorbent assay. More than 62 % of dust samples had detectable Asp f 1 levels (limit of detection 3.6 ng g(-1)). The overall mean Asp f 1 level was 17.9 ng g(-1) [range (3.8 to 72.4) ng g(-1)]. Satisfactory results were obtained for analytical within-run imprecision (6.7 %), between-run imprecision (10.5 %), and accuracy (91 % to 115 %). Microclimate parameters (air temperature, relative humidity, and velocity) were within the recommended ranges in all poultry farms. This study has shown that Asp f 1 settles on dust at poultry farms and that occupational exposure to this allergen deserves monitoring in livestock buildings.