The Center for School Mold Help

In addition to the Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture Indoors (US EPA and UCONN), this selection on the EPA website contains information for physicians related to indoor air problems and resulting biological exposures that can lead to disease.

Health Problems Caused By
ANIMAL DANDER, MOLDS, DUST MITES, OTHER BIOLOGICALS

Key Signs/Symptoms

• recognized infectious disease
• exacerbation of asthma
• rhinitis
• conjunctival inflammation
• recurrent fever
• malaise
• dyspnea
• chest tightness
• cough

Diagnostic Leads

Infectious disease:

• Is the case related to the workplace, home, or other location?
  (Note: It is difficult to associate a single case of any infectious disease with a specific site of exposure.)
• Does the location have a reservoir or disseminator of biologicals that may logically lead to exposure?

Hypersensitivity disease:

• Is the relative humidity in the home or workplace consistently above 50 percent?
• Are humidifiers or other water-spray systems in use? How often are they cleaned? Are they cleaned appropriately?
• Has there been flooding or leaks?
• Is there evidence of mold growth (visible growth or odors)?
• Are organic materials handled in the workplace?
• Is carpet installed on unventilated concrete (e.g., slab on grade) floors?
• Are there pets in the home?
• Are there problems with cockroaches or rodents?

Toxicosis and/or irritation:

• Is adequate outdoor air being provided?
• Is the relative humidity in the home or workplace above 50 percent or below 30 percent?
• Are humidifiers or other water-spray systems in use?
• Is there evidence of mold growth (visible growth or odors)?
• Are bacterial odors present (fishy or locker-room smells)?

Remedial Action

• Provide adequate outdoor air ventilation to dilute human source aerosols.
• Keep equipment water reservoirs clean and potable water systems adequately chlorinated, according to manufacturer instructions. Be sure there is no standing water in air conditioners. Maintain humidifiers and dehumidifiers according to manufacturer instructions.
• Repair leaks and seepage. Thoroughly clean and dry water-damaged carpets and building materials within 24 hours of damage, or consider removal and replacement.
• Keep relative humidity below 50 percent. Use exhaust fans in bathrooms and kitchens, and vent clothes dryers to outside.
• Control exposure to pets.
• Vacuum carpets and upholstered furniture regularly. Note: While it is important to keep an area as dust-free as possible, cleaning activities often re-suspend fine particles during and immediately after the activity. Sensitive individuals should be cautioned to avoid such exposure, and have others perform the vacuuming, or use a commercially available HEPA (High Efficiency Particulate Air) filtered vacuum.
• Cover mattresses. Wash bedding and soft toys frequently in water at a temperature above 130^oF to kill dust mites.

Comment

Biological air pollutants are found to some degree in every home, school, and workplace. Sources include outdoor air and human occupants who shed viruses and bacteria, animal occupants (insects and other arthropods, mammals) that shed allergens, and indoor surfaces and water reservoirs where fungi and bacteria can grow, such as humidifiers²³. A number of factors allow biological agents to grow and be released into the air. Especially important is high relative humidity, which encourages house dust mite populations to increase and allows fungal growth on damp surfaces. Mite and fungus contamination can be caused by flooding, continually damp carpet (which may occur when carpet is installed on poorly ventilated concrete floors), inadequate exhaust of bathrooms, or kitchen-generated moisture²⁴. Appliances such as humidifiers, dehumidifiers, air conditioners, and drip pans under cooling coils (as in refrigerators), support the growth of bacteria and fungi.

Components of mechanical heating, ventilating, and air conditioning (HVAC) systems may also serve as reservoirs or sites of microbial amplification²⁵. These include air intakes near potential sources of contamination such as standing water, organic debris or bird droppings, or integral parts of the mechanical system itself, such as various humidification systems, cooling coils, or condensate drain pans. Dust and debris may be deposited in the duct work or mixing boxes of the air handler.

Biological agents in indoor air are known to cause three types of human disease: infections, where pathogens invade human tissues; hypersensitivity diseases, where specific activation of the immune system causes disease; and toxicosis, where biologically produced chemical toxins cause direct toxic effects. In addition, exposure to conditions conducive to biological contamination (e.g., dampness, water damage) has been related to nonspecific upper and lower respiratory symptoms. Evidence is available that shows that some episodes of the group of nonspecific symptoms known as "sick building syndrome" may be related to microbial contamination in buildings²⁶.

Tuberculosis

The transmission of airborne infectious diseases is increased where there is poor indoor air quality^27,28. The rising incidence of tuberculosis is at least in part a problem associated with crowding and inadequate ventilation. Evidence is increasing that inadequate or inappropriately designed ventilation systems in health care settings or other crowded conditions with high-risk populations can increase the risk of exposure²⁹.

The incidence of tuberculosis began to rise in the mid 1980s, after a steady decline. The 1989 increase of 4.7 percent to a total of 23,495 cases in the United States was the largest since national reporting of the disease began in 1953, and the number of cases has continued to increase each year³⁰. Fresh air ventilation is an important factor in contagion control. Such procedures as sputum induction and collection, bronchoscopy, and aerosolized pentamidine treatments in persons who may be at risk for tuberculosis (e.g., AIDS patients) should be carried out in negative air pressure areas, with air exhausted directly to the outside and away from intake sources³¹. Unfortunately, many health care facilities are not so equipped. Properly installed and maintained ultraviolet irradiation, particularly of upper air levels in an indoor area, is also a useful means of disinfection³².

Legionnaires' Disease

A disease associated with indoor air contamination is Legionnaires' Disease, a pneumonia that primarily attacks exposed people over 50 years old, especially those who are immunosuppressed, smoke, or abuse alcohol. Exposure to especially virulent strains can also cause the disease in other susceptible populations. The case fatality rate is high, ranging from five to 25 percent. Erythromycin is the most effective treatment. The agent, Legionella pneumophila, has been found in association with cooling systems, whirlpool baths, humidifiers, food market vegetable misters, and other sources, including residential tap water³³. This bacterium or a closely related strain also causes a self-limited (two- to five-day), flu-like illness without pneumonia, sometimes called Pontiac Fever, after a 1968 outbreak in that Michigan city.

Allergic Reactions

A major concern associated with exposure to biological pollutants is allergic reactions, which range from rhinitis, nasal congestion, conjunctival inflammation, and urticaria to asthma. Notable triggers for these diseases are allergens derived from house dust mites; other arthropods, including cockroaches; pets (cats, dogs, birds, rodents); molds; and protein-containing furnishings, including feathers, kapok, etc. In occupational settings, more unusual allergens (e.g., bacterial enzymes, algae) have caused asthma epidemics. Probably most proteins of non-human origin can cause asthma in a subset of any appropriately exposed population³⁴.

The role of mites as a source of house dust allergens has been known for 20 years^34,35. It is now possible to measure mite allergens in the environment and IgE antibody levels in patients using readily available techniques and standardized protocols. Experts have proposed provisional standards for levels of mite allergens in dust that lead to sensitization and symptoms. A risk level where chronic exposure may cause sensitization is 2µg Der pI (Dermatophagoides pteronysinus allergen I) per gram of dust (or 100 mites /g or 0.6 mg guanine /g of dust). A risk level for acute asthma in mite-allergic individuals is 10µg (Der pI) of the allergen per gram of dust (or 500 mites /g of dust).

Controlling house dust mite infestation includes covering mattresses, hot washing of bedding, and removing carpet from bedrooms. For mite allergic individuals, it is recommended that home relative humidities be lower than 45 percent. Mites desiccate in drier air (absolute humidities below 7 kg.). Vacuum cleaning and use of acaricides can be effective short-term remedial strategies. One such acaracide, Acarosan, is registered with EPA to treat carpets, furniture, and beds for dust mites.

Hypersensitivity Pneumonitis

Another class of hypersensitivity disease is hypersensitivity pneumonitis, which may include humidifier fever. Hypersensitivity pneumonitis, also called allergic alveo-litis, is a granulomatous interstitial lung disease caused by exposure to airborne antigens. It may affect from one to five percent or more of a specialized population exposed to appropriate antigens (e.g., farmers and farmers' lung, pigeon breeders and pigeon breeders' disease)³⁷. Continued antigen exposure may lead to end-stage pulmonary fibrosis. Hypersensitivity pneumonitis is frequently misdiagnosed as a pneumonia of infectious etiology. The prevalence of hypersensitivity pneumonitis in the general population is unknown.

Outbreaks of hypersensitivity pneumonitis in office buildings have been traced to air conditioning and humidification systems contaminated with bacteria and molds³⁸. In the home, hypersensitivity pneumonitis is often caused by contaminated humidifiers or by pigeon or pet bird antigens. The period of sensitization before a reaction occurs may be as long as months or even years. Acute symptoms, which occur four to six hours postexposure and recur on challenge with the offending agent, include cough, dyspnea, chills, myalgia, fatigue, and high fever. Nodules and nonspecific infiltrates may be noted on chest films. The white blood cell count is elevated, as is specific IgG to the offending antigen. Hypersensitivity pneumonitis generally responds to corticosteroids or cessation of exposure (either keeping symptomatic people out of contaminated environments or removing the offering agents).

Humidifier Fever

Humidifier fever is a disease of uncertain etiology³⁹. It shares symptoms with hypersensitivity pneumonitis, but the high attack rate and short-term effects may indicate that toxins (e.g., bacterial endotoxins) are involved. Onset occurs a few hours after exposure. It is a flu-like illness marked by fever, headache, chills, myalgia, and malaise but without prominent pulmonary symptoms. It normally subsides within 24 hours without residual effects, and a physician is rarely consulted. Humidifier fever has been related to exposure to amoebae, bacteria, and fungi found in humidifier reservoirs, air conditioners, and aquaria. The attack rate within a workplace may be quite high, sometimes exceeding 25 percent.

Bacterial and fungal organisms can be emitted from impeller (cool mist) and ultrasonic humidifiers. Mesophilic fungi, thermophilic bacteria, and thermophilic actinomycetes -- all of which are associated with development of allergic responses -- have been isolated from humidifiers built into the forced-air heating system as well as separate console units. Airborne concentrations of microorganisms are noted during operation and might be quite high for individuals using ultrasonic or cool mist units. Drying and chemical disinfection with bleach or 3% hydrogen peroxide solution are effective remedial measures over a short period, but cannot be considered as reliable maintenance. Only rigorous, daily, and end-of-season cleaning regimens, coupled with disinfection, have been shown to be effective. Manual cleaning of contaminated reservoirs can cause exposure to allergens and pathogens.

Mycotoxins

Another class of agents that may cause disease related to indoor airborne exposure is the mycotoxins. These agents are fungal metabolites that have toxic effects ranging from short-term irritation to immunosuppression and cancer. Virtually all the information related to diseases caused by mycotoxins concerns ingestion of contaminated food⁴⁰. However, mycotoxins are contained in some kinds of fungus spores, and these can enter the body through the respiratory tract. At least one case of neurotoxic symptoms possibly related to airborne mycotoxin exposure in a heavily contaminated environment has been reported⁴¹. Skin is another potential route of exposure to mycotoxins. Toxins of several fungi have caused cases of severe dermatosis. In view of the serious nature of the toxic effects reported for mycotoxins, exposure to mycotoxin-producing agents should be minimized.