"Recent research suggests that indoor mold poses a widespread and, for some people, serious health threat." (US General Accounting Office, 2008)
The GAO (USA General Accounting Office) Audit on Mold that took two years to complete is now posted and public, on the GAO site, as well as below (SMH).
"The U.S. Government Accountability Office (GAO) is known as "the investigative arm of Congress" and "the congressional watchdog." GAO supports the Congress in meeting its constitutional responsibilities and helps improve the performance and accountability of the federal government for the benefit of the American people. Read More About GAO" (US GAO)
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This groundbreaking report refutes the notion that mold is only a nuisance or minor allergen. It is a key document to use in any venue where one might wish to cite the serious nature of mold exposure - in our schools, homes, offices or other buildings. Parents with children in damp or moldy schools will be able to use this document to show that there is no safe level of mold exposure. Parents of students concerned about or harmed by mold exposures will want to use this document with their school districts, school boards, health departments, physicians, and attorneys. Teachers and school staff concerned about or harmed by mold will want to provide this document to their physicians, unions, local OSHA, health departments and attorneys.
Gone is the day when denials of the health effects of mold exposures are accepted. Mold remediation will improve with consistent direction from our government. People will be adequately warned of the health risks of indoor mold exposure.
Our sincere thanks to Senator Ted Kennedy for requesting this audit and to those who tirelessly lobbied for it. We hope this is the beginning of an era of greater accuracy, research, and consistency among the US gov't agencies, with regard to mold's health effects and its prevention, that will greatly improve the health of our nation. (SMH)
Indoor Mold: Better Coordination of Research on Health Effects and More Consistent Guidance Would Improve Federal Efforts
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Report to the Chairman, Committee on Health, Education, Labor and Pensions, U.S. Senate
United States Government Accountability Office
GAO
September 2008
INDOOR MOLD
Better Coordination of
Research on Health
Effects and More
Consistent Guidance
Would Improve
Federal Efforts
GAO-08-980
To view the full product, including the scope
and methodology, click on GAO-08-980. To
view the survey results, click on GAO-08-
984SP. For more information, contact John B.
Stephenson at (202) 512-3841 or
This e-mail address is being protected from spam bots, you need JavaScript enabled to view it
Highlights of GAO-08-980, a report to the
Chairman, Committee on Health,
Education, Labor and Pensions,
U.S. Senate
September 2008
INDOOR MOLD
Better Coordination of Research on Health Effects
and More Consistent Guidance Would Improve
Federal Efforts
Text Box: Recent research suggests that indoor mold poses a widespread and, for some people, serious health threat. Federal agencies engage in a number of activities to address this issue, including conducting or sponsoring research. For example, in 2004 the National Academies’ Institute of Medicine issued a report requested by the Department of Health and Human Services (HHS) summarizing the scientific literature on mold, dampness, and human health. In addition, the Federal Interagency Committee on Indoor Air Quality supports the Environmental Protection Agency’s (EPA) indoor air research program. With respect to the health effects of exposure to indoor mold, GAO was asked to report on (1) the conclusions of recent reviews of the scientific literature, (2) the extent to which federal research addresses data gaps, and (3) the guidance agencies are providing to the general public. GAO reviewed scientific literature on indoor mold’s health effects, surveyed three agencies that conduct or sponsor indoor mold research, and analyzed guidance issued by five agencies.
GAO recommends that EPA use the interagency committee on indoor air to (1) help guide federal research priorities on indoor mold and (2) help agencies better ensure that their guidance to the public does not conflict, among other things. In commenting on a draft of our report, EPA agreed with our recommendations.
Text Box: In general, the Institute of Medicine’s 2004 report, and reviews of the scientific literature published from 2005 to 2007 that GAO examined, concluded that certain adverse health effects are more clearly associated with exposure to indoor mold than others. For example, the Institute of Medicine concluded that some respiratory effects, such as exacerbation of pre-existing asthma, are associated with exposure to indoor mold but that the available evidence was not sufficient to determine whether mold and a variety of other health effects, such as the development of asthma, cancer, and acute pulmonary hemorrhage in infants, are associated. While the reviews GAO examined generally agreed with these conclusions, a few judged the evidence for some health effects as somewhat stronger. For example, the American Academy of Pediatrics concluded in 2006 that a plausible link exists between acute pulmonary hemorrhage in infants and exposure to toxins that some molds produce. In addition, the 2004 Institute of Medicine report identified the need for additional research to address a number of data gaps related to the health effects of indoor mold.
The 65 ongoing federal research activities on the health effects of exposure to indoor mold conducted or sponsored by EPA, HHS, and the Department of Housing and Urban Development (HUD) address to varying extents 15 gaps in scientific data reported by the Institute of Medicine. For example, many of the research activities address data gaps related to asthma and measurement methods, while other data gaps, such as those related to toxins produced by some molds, are being minimally addressed. Further, less than half of the ongoing mold-related research activities are coordinated either within or across agencies. This limited coordination is important in light of, among other things, the wide range of data gaps identified by the Institute of Medicine and limited federal resources. The Federal Interagency Committee on Indoor Air Quality could provide a structured mechanism for coordinating research activities on mold and other indoor air issues by, for example, serving as a forum for reviewing and prioritizing agencies’ ongoing and planned research. However, it currently does not do so.
Despite limitations of scientific evidence regarding a number of potential health effects of exposure to indoor mold, enough is known that federal agencies have issued guidance to the general public about health risks associated with exposure to indoor mold and how to minimize mold growth and mitigate exposure. For example, guidance issued by the Consumer Product Safety Commission, EPA, the Federal Emergency Management Agency, HHS, and HUD cites a variety of health effects of exposure to indoor mold but in some cases omits less common but serious effects. Moreover, while guidance on minimizing indoor mold growth is generally consistent, guidance on mitigating exposure to indoor mold is sometimes inconsistent about cleanup agents, protective clothing and equipment, and sensitive populations. As a result, the public may not be sufficiently advised of indoor mold’s potential health risks.
Health Effects of Indoor Mold
Contents
Letter 1
Results in Brief 4Background 7
Many Studies Associate Indoor Mold with Adverse Health Effects
but Cite the Need for Additional Research 11
Federal Research Activities on the Health Effects of Indoor Mold
Address Data Gaps to Varying Degrees; Limited Planning and
Coordination of the Activities May Reduce Their Ability to Close
Data Gaps 20
Federal Guidance to the General Public Identifies Various Health
Effects Associated with Exposure to Indoor Mold, as well as
Strategies to Limit It, Some of Which Are Inconsistent 32
Conclusions 39
Recommendations for Executive Action 41
Agency Comments and Our Evaluation 41
Appendix I Objectives, Scope, and Methodology 43
Appendix II Recent Reviews of the Health Effects of Mold 48
Appendix III EPA, HHS, and HUD Ongoing Research
Activities Addressing Data Gaps Identified by
the Institute of Medicine 50
Appendix IV Federal Agency Program Offices Contacted
Regarding Their Mold-Related Research 52
Appendix V Selected Publicly Available Federal Guidance
Related to Mold 56
Appendix VI GAO Contact and Staff Acknowledgments 60
Health Effects of Indoor Mold
Table
Table 1: Potential Adverse Health Effects of Exposure to Indoor
Mold Cited in Six or More Guidance Documents, by
Federal Agency 33
Figures
Figure 1: Coordination of Ongoing Federal Mold Research
Activities within the Agency or among Other Federal
Agencies, as of October 1, 2007 29
Figure 2: Varying Levels of Personal Protection for Cleaning
Limited Mold Contamination, as Recommended by
Selected Federal Guidance 38
Abbreviations
CDC Centers for Disease Control and Prevention
DOE Department of Energy
EPA Environmental Protection Agency
ERMI Environmental Relative Moldiness Index
FEMA Federal Emergency Management Agency
HHS Department of Health and Human Services
HUD Department of Housing and Urban Development
NIH National Institutes of Health
NIOSH National Institute for Occupational Safety and Health
OSHA Occupational Safety and Health Administration
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Health Effects of Indoor Mold Indoor Mold
United States Government Accountability Office
Washington, DC 20548
September 30, 2008 September 30, 2008
The Honorable Edward M. Kennedy
Chairman
Committee on Health, Education,
Labor and Pensions
United States Senate
The Honorable Edward M. Kennedy
Chairman
Committee on Health, Education,
Labor and Pensions
United States Senate
Dear Mr. Chairman: Dear Mr. Chairman:
Mold is a general term for certain microorganisms that thrive in damp
conditions and are regularly found in indoor air and on materials and
surfaces, such as walls.1 While indoor mold was considered largely a
nuisance as recently as 25 years ago, scientific and medical research is
now suggesting that mold poses a widespread and, for some people,
serious health threat.2 The presence of moisture is the primary factor
leading to mold growth indoors. In the wake of Hurricanes Katrina and
Rita in 2005 and the extensive flooding of homes that followed, the
Department of Health and Human Services’ (HHS) Centers for Disease
Control and Prevention (CDC) concluded that “excessive exposure to
mold-contaminated materials can cause adverse health effects in
susceptible persons regardless of the type of mold or the extent of
contamination.”3123 A variety of health effects have been directly linked to
exposure to indoor mold, although the connection to many of the more
severe effects, such as acute lung hemorrhaging in infants, remains
inconclusive.
Mold is a general term for certain microorganisms that thrive in damp
conditions and are regularly found in indoor air and on materials and
surfaces, such as walls. While indoor mold was considered largely a
nuisance as recently as 25 years ago, scientific and medical research is
now suggesting that mold poses a widespread and, for some people,
serious health threat. The presence of moisture is the primary factor
leading to mold growth indoors. In the wake of Hurricanes Katrina and
Rita in 2005 and the extensive flooding of homes that followed, the
Department of Health and Human Services’ (HHS) Centers for Disease
Control and Prevention (CDC) concluded that “excessive exposure to
mold-contaminated materials can cause adverse health effects in
susceptible persons regardless of the type of mold or the extent of
contamination.” A variety of health effects have been directly linked to
exposure to indoor mold, although the connection to many of the more
severe effects, such as acute lung hemorrhaging in infants, remains
inconclusive.
Several components and products of mold may cause disease. Mold grows
as a mass of microscopic filaments, fragments of which may cause adverse
health effects. In addition, the spores that mold releases to reproduce,
along with certain components of mold’s cell walls, may also cause
adverse health effects. Mold products—for example, allergens, volatile
Several components and products of mold may cause disease. Mold grows
as a mass of microscopic filaments, fragments of which may cause adverse
health effects. In addition, the spores that mold releases to reproduce,
along with certain components of mold’s cell walls, may also cause
adverse health effects. Mold products—for example, allergens, volatile
1In this report, we use the term “mold” to refer to the large number of species of fungi.
2National Institute of Environmental Health Sciences, “A Spreading Concern: Inhalational
Health Effects of Mold,” Environmental Health Perspectives (June 2007).
3Department of Health and Human Services, Centers for Disease Control and Prevention,
Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes
and Major Floods (Atlanta, 2006).
Health Effects of Indoor Mold
gases that often create a musty odor, and toxins released by certain types
of mold under certain conditions—can also cause disease. An example of
a toxin-producing mold is Stachybotrys chartarum, which produces
multiple toxins that may suppress the functioning of immune cells.
Mold may affect human health through a number of routes and
mechanisms. While inhalation is generally the most common route of
exposure for mold in indoor environments, exposure can also occur
through ingestion (for example, hand-to-mouth contact) and contact with
the skin. The roles of these routes of exposure in causing illness are
unclear. Once exposure occurs, health effects may arise through several
potential mechanisms, including allergic (or immune-mediated),
infectious, and toxic. It is not always possible to determine which of these
mechanisms is associated with a specific health outcome.
Although federal agencies are engaged in a number of efforts to address
indoor mold, there are no federal or generally accepted health-based
standards for safe levels of mold in the air or on surfaces. According to
EPA officials, the lack of federal regulation of airborne concentrations of
mold indoors is largely due to the insufficiency of data needed to establish
a scientifically defensible health-based standard. Another factor is the lack
of scientific consensus regarding how best to measure these
concentrations. The presence of mold in homes and workplaces has led to
numerous lawsuits. For example, highly publicized cases involving mold
include a Texas homeowner’s successful multi-million-dollar lawsuit
against an insurance company related to mold contamination. Moreover,
mold contamination at the Walter Reed Army Medical Center, where
soldiers returning from Iraq are being treated, received significant media
coverage.
In 2001, recognizing the need for credible and comprehensive information
on the health effects of exposure to indoor mold, HHS commissioned the
National Academies’ Institute of Medicine to review the available scientific
literature on the links among mold, dampness, and human health.4 In 2004,
the Institute of Medicine issued its report, which made a variety of
recommendations for research aimed at better understanding the health
4The National Academies comprises four organizations: the National Academy of Sciences,
the National Academy of Engineering, the Institute of Medicine, and the National Research
Council.
Health Effects of Indoor Mold
risks of exposure to indoor mold.5 Currently, a number of federal agencies
conduct mold-related research or provide guidance to the public on health
effects associated with exposure to mold and on ways to mitigate such
exposure. These federal agencies include the Environmental Protection
Agency (EPA); the Department of Housing and Urban Development
(HUD); the Consumer Product Safety Commission; the Federal Emergency
Management Agency (FEMA); and HHS and a number of its entities, such
as CDC and the National Institutes of Health (NIH). In 1983, a
congressional committee directed the establishment of the Federal
Interagency Committee on Indoor Air Quality to coordinate federal indoor
air quality research. The research on indoor mold is a small component of
indoor air research activities, and it is conducted or sponsored by a
number of different entities within and across agencies. EPA serves both
as the executive secretary of the interagency committee and as a co-chair;
other federal departments and agencies participate as co-chairs and
members.
You asked us to determine (1) what recent reviews of scientific literature
have concluded about the health effects of exposure to indoor mold; (2)
the extent to which federal research addresses data gaps related to the
health effects of exposure to indoor mold; and (3) the guidance key federal
agencies are providing to the general public on the health risks of
exposure to mold, minimizing mold growth, and mitigating exposure to
mold, and the extent to which the guidance is consistent. For the first
objective, we analyzed the 2000 and 2004 Institute of Medicine reports,
Clearing the Air: Asthma and Indoor Air Exposures and Damp Indoor
Spaces and Health.6 We also analyzed 20 reviews of the scientific literature
on the health effects of exposure to indoor mold that were published from
2005 to 2007; we did not review individual studies. To obtain information
on federal research related to the health effects of exposure to indoor
mold, we conducted two surveys of officials at EPA, HHS, and HUD from
November 2007 to May 2008. We focused on these agencies because of
their past and current research activities on the health effects of mold. We
used one survey to (1) identify research activities related to the health
effects of indoor mold ongoing as of October 1, 2007, and (2) determine
the extent to which these research activities address the 15 data gaps
5Institute of Medicine, Damp Indoor Spaces and Health (Washington, D.C.: The National
Academies Press, 2004).
6Institute of Medicine, Clearing the Air: Asthma and Indoor Air Exposures (Washington,
D.C.: National Academy Press, 2000).
Health Effects of Indoor Mold
identified in the 2000 and 2004 Institute of Medicine reports related to the
health effects of exposure to indoor mold. We also used this survey to
identify the extent to which these activities were coordinated both within
and across agencies. We conducted a second survey of these agencies to
collect basic information regarding their mold-related research activities
completed from January 1, 2005, to September 30, 2007. Overall, we
received information on 107 research activities from 37 EPA, HHS, and
HUD officials. Summaries of the research activities conducted or
sponsored by EPA, HHS, and HUD are provided in a supplement to this
report (see GAO-08-984SP). We also examined the extent to which the
Federal Interagency Committee on Indoor Air Quality has been used to
coordinate federal research activities related to the health effects of
exposure to indoor mold. To evaluate guidance documents issued to the
public by federal agencies, we focused on the five federal agencies
primarily responsible for providing information to the general public on
health risks and minimizing and mitigating exposure to contaminants,
including mold—the Consumer Product Safety Commission, EPA, FEMA,
HHS, and HUD. Our review focuses on the health effects and guidance to
the general public related to indoor mold in homes and does not address
occupational exposures or technical guidance documents targeted to
specialized audiences such as medical professionals. Appendix I provides
a more detailed description of our scope and methodology. We conducted
this performance audit from January 2007 to September 2008 in
accordance with generally accepted government auditing standards. Those
standards require that we plan and perform the audit to obtain sufficient,
appropriate evidence to provide a reasonable basis for our findings and
conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions
based on our audit objectives.
Results in Brief
In general, the Institute of Medicine’s 2004 comprehensive report, as well
as reviews of the scientific literature published from 2005 to 2007 that we
examined, concluded that certain adverse health effects are more clearly
associated with exposure to indoor mold than others. For example, the
Institute of Medicine’s report said that certain respiratory effects, such as
nasal congestion and the exacerbation of pre-existing asthma, are
associated with exposure to indoor mold but that the available evidence
was not sufficient to determine whether associations exist between mold
and a variety of other health effects, such as the development of asthma,
rheumatologic and other immune diseases, cancer, acute pulmonary
hemorrhage in infants, and reproductive effects. While the more recent
scientific reviews we examined generally concurred with these
Health Effects of Indoor Mold
conclusions, a few of the reviews judged the available evidence for some
of these health effects to be somewhat stronger. For example, the
American Academy of Pediatrics concluded in 2006 that a plausible link
exists between acute pulmonary hemorrhage in infants and exposure to
certain toxins that some molds produce. Conclusively associating
exposure to mold with certain health effects is challenging, according to
the Institute of Medicine’s 2004 report, because available studies have
been of insufficient quality, consistency, or rigor. Two key research issues
contribute to this difficulty: (1) the lack of standardized, quantitative
methods of measuring exposure to mold and (2) the difficulty in
determining which of several disease-causing agents in damp indoor
environments may be responsible for the adverse health effects. In this
regard, the 2000 and 2004 Institute of Medicine reports and the more
recent reviews we examined identified the need for additional research to
address these and other uncertainties related to the connection between
exposure to indoor mold and adverse health effects. For example, the 2004
Institute of Medicine report concluded that there is a need for research to
determine the health effects of long-term exposure to the toxins that some
molds can produce.
The 65 ongoing federal research activities on the health effects of
exposure to indoor mold conducted or sponsored by EPA, HHS, and HUD
address to varying extents 15 gaps in scientific data reported by the
Institute of Medicine. These gaps relate to the need to better define any
association between a wide range of specific potential adverse health
effects and exposure to indoor mold. Of the 65 research activities, nearly
60 percent address asthma, and more than half address measurement
methods—that is, sampling and exposure assessment methods for indoor
mold. Some other important data gaps are being minimally addressed. For
example, 5 of the 65 research activities examine the effects of human
exposure to molds that produce toxins that may cause a number of
adverse health effects, and only 1 relates to acute pulmonary hemorrhage
in infants—a rare but life-threatening condition that may be caused by
exposure to mold. Further, identifying and coordinating research
priorities, and efforts to achieve them, are particularly important given the
wide range of research needs identified by the Institute of Medicine
reports, the number of federal entities involved in conducting research on
mold, and limited federal resources. However, federal officials reported
that fewer than half of their ongoing research activities have involved
coordination either with other units in their agencies or other federal
agencies. For example, of the 36 ongoing research activities related to
sampling and measurement methods, only 14 are being coordinated to
some extent. Further, in many cases, research activities were only
Health Effects of Indoor Mold
coordinated within the agency conducting or sponsoring the research.
Moreover, although the Federal Interagency Committee on Indoor Air
Quality could provide a structured mechanism for coordinating research
activities, it does not serve this function. That is, instead of selecting
specific topics and tasks to advance scientific knowledge in the area of
indoor air quality—such as reviewing and prioritizing agencies’ ongoing
and planned research in particular areas—the agendas for the committee
meetings are largely driven by the interests of the agencies’ individual
committee representatives.
Despite the limitations of current scientific evidence in establishing clear
associations and causal linkages between a number of adverse health
effects and exposure to indoor mold, enough is known that federal
agencies have issued guidance to the general public about health risks
associated with exposure to indoor mold, how to minimize mold growth,
and how to mitigate exposure. For example, a majority of the 32 guidance
documents we reviewed issued by the Consumer Product Safety
Commission, EPA, FEMA, HHS, and HUD describe some common adverse
health effects, such as asthma attacks and upper respiratory tract
symptoms. However, the guidance documents inconsistently identify some
other health effects that may be less common. For example, only 6 of the
32 documents warn that exposure to mold can lead to hypersensitivity
pneumonitis, a relatively rare but potentially serious allergic reaction. In
addition, most of the guidance documents offer consistent strategies for
minimizing the growth of indoor mold—for example, keeping areas dry
and promptly addressing moisture sources, such as leaks or spills. Finally,
a majority of the documents also address mitigating exposure to indoor
mold, including directions for cleaning up mold and protective clothing
and equipment to wear while doing so. However, the guidance is
somewhat inconsistent about which cleaning agents to use—for example,
some documents recommend using bleach, a biocide that is toxic to
humans, if the mold growth is due to floodwater; some recommend bleach
regardless of the cause of the mold; and others recommend using
detergent. Finally, most of the documents warn that certain populations
may be more sensitive to mold than others, but only two provide specific
recommendations about the varying levels of protective clothing and
equipment (such as gloves, respirators, and eye and skin protection) that
such populations should use under various circumstances. As a result of
some of these omissions and inconsistencies, the public may be at risk of
unnecessary exposure to indoor mold.
To better ensure that federal research on the health effects of exposure to
indoor mold is effectively addressing research needs and efficiently using
Health Effects of Indoor Mold
scarce federal resources, we are recommending that EPA use the Federal
Interagency Committee on Indoor Air Quality to both (1) help guide
federal research priorities on the health effects of indoor mold and
coordinate information sharing on this topic and (2) help agencies better
ensure that their guidance to the public provides sufficient information on
health effects of exposure to indoor mold, and how to minimize it, and
does not conflict among agencies. We provided a draft of this report to the
Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD for
the agencies’ review and comment. EPA generally agreed with our
recommendations regarding its use of the Federal Interagency Committee
on Indoor Air Quality. With the exception of FEMA, the agencies also
provided technical comments that we incorporated into the report, as
appropriate.
Background
Moisture is the primary factor leading to indoor mold growth. To grow
indoors, mold also needs temperatures above freezing levels—from 32 to
130 degrees Fahrenheit—and organic matter. The nutrients upon which
mold feeds are provided by house dust and many surface and construction
materials, such as wallpapers, textiles, wood, paints, and glues. Because
the appropriate temperature and necessary nutrients are common in
homes, mold growth can rapidly occur indoors when excessive moisture
or water accumulates as a result of, for example, floods and other natural
disasters; building design or construction flaws; and poor building
maintenance practices, such as not repairing leaking plumbing. Moist
conditions indoors may also foster the growth of other organisms capable
of causing adverse health effects, including bacteria, cockroaches, and
dust mites.
Mold growth may be particularly severe following natural disasters such as
hurricanes and flooding. The extent of the flooding after Hurricanes
Katrina and Rita in 2005 led to conditions supporting widespread mold
growth. Unlike other hurricane-impacted areas, where residents could
access their buildings relatively quickly after the flood event, many
residents in New Orleans were unable to access buildings for several
weeks because of prolonged flood inundation. According to a CDC survey,
an estimated 46 percent of homes in New Orleans and surrounding areas
had visible mold growth. Widespread indoor mold contamination can
cause adverse health effects in returning residents and make it more
difficult to rehabilitate houses for reoccupation. For example, in 2006 the
Army Corps of Engineers noted that because of mold problems caused by
the extensive flooding, many residences that did not require demolition
Health Effects of Indoor Mold
would nonetheless need to be gutted—stripping the walls down to the
studs—before they could be renovated.7
The Institute of Medicine has identified four possible levels of connection
between indoor mold and adverse health effects: sufficient evidence of a
causal relationship, sufficient evidence of an association, limited or
suggestive evidence of an association, and inadequate or insufficient
evidence to determine whether an association exists. According to HHS,
establishing a causal relationship with adequate certainty requires several
types of evidence, including (1) epidemiologic associations, (2)
experimental exposure in animals or humans that leads to the symptoms
and signs of the disease in question, and (3) reduction in exposure that
leads to reduction in the symptoms and signs of the disease. HHS officials
said that more data are needed to establish a causative association
between exposure to mold and some illnesses because the vast majority of
the studies conducted to date have been only epidemiologic.
The federal government has responded to the uncertainty surrounding the
health effects of exposure to indoor mold by, among other things,
sponsoring reviews of the available scientific evidence. Committees of the
National Academies’ Institute of Medicine have produced two reports in
the past several years that relate to the health effects of exposure to
indoor mold. For a 2000 report requested by EPA, Clearing the Air:
Asthma and Indoor Air Exposures, the Institute of Medicine assembled a
multidisciplinary committee to examine the relevant research pertaining to
asthma and the indoor environment, including, among many other issues,
the possible impact of indoor mold on asthma prevalence. For its 2004
report requested by the CDC, Damp Indoor Spaces and Health, another
Institute of Medicine committee reviewed the scientific literature to
determine the connections among damp indoor spaces, microorganisms
such as mold, and a variety of human health effects. This committee used
a uniform set of categories to summarize its conclusions regarding the
evidence of association between various health outcomes and exposure to
indoor dampness or the presence of mold or other agents in damp indoor
environments. While research in this field continues to evolve, both
reports made recommendations for additional research related to mold
7GAO, Hurricane Katrina: EPA’s Current and Future Environmental Protection Efforts
Could Be Enhanced by Addressing Issues and Challenges Faced on the Gulf Coast,
GAO-07-651 (Washington, D.C.: June 25, 2007).
Health Effects of Indoor Mold
and other areas that remain relevant—that is, the data gaps have not been
resolved.
In addition to sponsoring reviews of the available scientific evidence,
federal agencies have the opportunity to share information on various
aspects of indoor air quality, including mold, through the Federal
Interagency Committee on Indoor Air Quality. Title IV of the Superfund
Amendments and Reauthorization Act of 1986 directed EPA, among other
things, to disseminate the results of its indoor air quality research program
and establish an advisory committee consisting of other federal agencies.8
EPA serves as the executive secretary of the Federal Interagency
Committee on Indoor Air Quality, which fulfills this advisory role. The
committee is co-chaired by EPA, the Department of Energy (DOE), the
Consumer Product Safety Commission, the National Institute for
Occupational Safety and Health (NIOSH), and the Occupational Safety and
Health Administration (OSHA). Other federal departments and agencies
participate in the committee as members. In 1991, we recommended that
the Administrator, EPA, work with other members of the committee to
clearly define in a charter the roles and responsibilities of the agencies
participating in the committee in order to strengthen interagency
coordination of indoor air research.9 However, EPA has not implemented
this recommendation.
Although federal agencies are engaged in a number of efforts to address
indoor mold, there are no federal or generally accepted health-based
standards for safe levels of mold, its components, or its products in the air
or on surfaces. In fact, neither EPA nor OSHA has established health-
based standards for airborne concentrations of mold or mold spores
indoors. Similarly, NIOSH has not set recommended exposure limits for
indoor mold or mold spores. Further, according to EPA officials, the lack
of federal regulation of airborne concentrations of mold indoors is largely
attributable to the insufficiency of data needed to establish a scientifically
defensible health-based standard. EPA officials also emphasized that the
agency lacks the authority to establish airborne concentration limits for
mold indoors. Legislation to require EPA to take action with respect to
indoor mold has been introduced in Congress in the past but was not
enacted. For example, the proposed United States Toxic Mold Safety and
8Pub. L. No. 99-499, Title IV, §§ 401 to 405 (1986).
9GAO, Indoor Air Pollution: Federal Efforts Are Not Effectively Addressing a Growing
Problem, GAO/RCED-92-8 (Washington, D.C.: Oct. 15, 1991).
Health Effects of Indoor Mold
Prevention Act, most recently introduced in Congress in 2005, would have
directed EPA to promulgate standards for preventing, detecting, and
remediating indoor mold growth, among other things.
The presence of mold in homes and workplaces has led to numerous
lawsuits alleging personal injury or property damage. To obtain a
judgment that mold has caused personal injury, an individual must
persuade the court that the type of mold at issue is capable of causing the
individual’s condition and that the mold actually caused the condition in
the specific case. Litigants generally use expert witness testimony in an
attempt to prove or disprove these points in court. Courts use different
standards to judge whether such testimony is admissible. In some states,
courts will admit such testimony only if it is in accord with generally
accepted consensus of the relevant scientific community. In other states
and in the federal courts, judges independently evaluate the reliability of
the evidence by weighing several factors, only one of which focuses on the
views of the relevant scientific community. Many state courts use a
mixture of these two methods.
Insurance companies are frequently defendants in mold litigation, and in
response to the rise in cases early in the decade, many began changing
their policies to specifically exclude mold-related injuries and property
damage from coverage. For example, many insurance policies now contain
language stating that the insurance company “will not pay for loss or
damage caused by or resulting from ... rust, corrosion, fungus, decay,” and
other conditions. As of 2006, the insurance regulatory agencies in 40 states
had approved mold-related exclusions.
Partly in response to a significant increase in mold litigation in the early
part of this decade, states began enacting legislation to address various
aspects of the mold problem. For example, in 2001 California enacted the
Toxic Mold Protection Act, which requires the state’s Department of
Health Services to establish permissible mold exposure limits for indoor
air.10 In addition, in 2003, Texas passed legislation requiring a mold
remediation contractor to certify to a homeowner that the mold
contamination identified for the project had been remediated as outlined
in the mold management plan or remediation protocol. Further, the Texas
law requires owners selling property to provide buyers with copies of each
10According to CDC officials, it is not yet possible to establish mold exposure limits for
indoor air.
Health Effects of Indoor Mold
mold remediation certificate issued for the properties the 5 preceding
years. Examples of other state legislative responses to mold issues include
laws
• requiring landlords to disclose to tenants information about the health
hazards associated with exposure to indoor mold;
• prohibiting litigation against a real estate agent acting on behalf of a buyer
or seller who has truthfully disclosed any known material defects;
• establishing licensing requirements for individuals involved with mold
assessment and remediation; and
• creating a group to study the effects of toxic mold.11
While the 2004 Institute of Medicine report, and reviews of the scientific
literature published subsequently, have found evidence associating indoor
mold with certain adverse health effects, the evidence supporting an
association between mold and other health effects remains less certain.
Two factors, in particular, pose challenges for those attempting to
determine the health effects of exposure to indoor mold: valid quantitative
methods of measuring exposure are lacking, and a wide variety of other
potential disease-causing agents are likely to be present in damp indoor
environments, along with mold. According to the Institute of Medicine and
recent reviews of the scientific literature, further research is required to
advance the understanding of the relationships between dampness, indoor
mold, and human health.
The 2004 Institute of Medicine report, Damp Indoor Spaces and Health,
found sufficient evidence of an association between exposure to indoor
mold and certain adverse health effects—that is, an association between
the agent and the outcome has been observed in studies in which chance,
bias, and confounding factors can be ruled out with reasonable
confidence. These health effects include
Many Studies
Associate Indoor
Mold with Adverse
Health Effects but
Cite the Need for
Additional Research
While Mold Is Associated
with Certain Adverse
Health Effects, Evidence
for Others Is Less Certain
11Information on state laws comes from data assembled by the National Association of
Mutual Insurance Companies (NAMIC) at www.namic.org.
Health Effects of Indoor Mold
• upper respiratory tract symptoms, including nasal congestion, sneezing,
runny or itchy nose, and throat irritation;
• exacerbation of pre-existing asthma;
• wheeze;
• cough;
• hypersensitivity pneumonitis in susceptible persons; and
• fungal colonization or opportunistic infections in immune-compromised
persons.
Of these health effects, the upper respiratory tract symptoms associated
with allergic rhinitis are the most common, according to the American
Academy of Pediatrics.12 In addition, the association between indoor mold
and exacerbation of asthma symptoms is a particularly significant public
health concern because asthma is the most common chronic illness among
children in the United States and one of the most common chronic
illnesses overall, according to the Institute of Medicine’s 2000 report,
Clearing the Air: Asthma and Indoor Air Exposures. Importantly, mold
can affect certain populations disproportionately. For example, the 2004
Institute of Medicine report found sufficient evidence of an association
between exposure to the mold genus Aspergillus and serious respiratory
infections in people with severely compromised immune systems (such as
chemotherapy patients and organ transplant recipients). This report also
found sufficient evidence of an association between exposure to indoor
mold and hypersensitivity pneumonitis—a relatively rare but potentially
serious allergic reaction—in susceptible persons. In addition to these
more established health effects, this report also found limited or
suggestive evidence of an association between indoor mold and lower
respiratory illness (for example, bronchitis and pneumonia) in otherwise
healthy children.
Most of the 20 reviews of the scientific literature published from 2005 to
2007 that we examined generally agreed with the conclusions of the 2004
12L.J. Mazur, J. Kim, and Committee on Environmental Health, American Academy of
Pediatrics, “Spectrum of Noninfectious Health Effects From Molds,” Pediatrics, vol. 118,
no. 6 (2006).
Health Effects of Indoor Mold
Institute of Medicine report.13 However, two of the reviews characterized
the relationship between exposure to indoor mold and certain of the above
health effects more strongly. The American Academy of Pediatrics stated
in its 2006 report that epidemiologic studies consistently support causal
relationships between exposure to mold and upper respiratory tract
symptoms and exacerbation of pre-existing asthma. The American
Academy of Pediatrics also said that epidemiologic studies support a
causal relationship between exposure to mold and hypersensitivity
pneumonitis in susceptible persons.14 Moreover, a 2007 meta-analysis15
sponsored by EPA and DOE found that building dampness and mold are
associated with increases of 30 percent to 50 percent in a variety of health
outcomes, such as upper respiratory tract symptoms, wheeze, and cough.
The authors concluded that these associations strongly suggest these
adverse health effects are caused by dampness-related exposures.16
According to the 2004 Institute of Medicine report, the evidence of an
association between exposure to indoor mold and a variety of other health
effects, however, is inadequate or insufficient—that is, the available
studies are of insufficient quality, consistency, or statistical power to
permit a conclusion regarding the presence of an association. The health
effects for which there is inadequate or insufficient evidence of an
association with indoor mold include
• acute idiopathic pulmonary hemorrhage in infants;
• airflow obstruction in otherwise-healthy persons;
• cancer;
13Two of the reviews focused primarily on clinical cases encountered by the authors. For a
list of the studies we reviewed, see appendix II.
14The authors of this report acknowledged that, because of the presence of other potential
disease-causing agents indoors, it is not possible to definitively attribute a causal
relationship to any one specific agent in indoor environments.
15A meta-analysis uses statistical methods to combine data from different but comparable
research studies, in order to provide a quantitative summary estimate on the size and
variability of an association.
16W.J. Fisk, Q. Lei-Gomez, and M.J. Mendell, “Meta-analyses of the associations of
respiratory health effects with dampness and mold in homes,” Indoor Air, vol. 17, no. 4
(2007).
Health Effects of Indoor Mold
• chronic obstructive pulmonary disease;
• development of asthma;
• fatigue;
• gastrointestinal tract problems;
• inhalation fevers not related to occupational exposures;
• lower respiratory illness in otherwise-healthy adults;
• mucous membrane irritation syndrome;
• neuropsychiatric symptoms;
• reproductive effects;
• rheumatologic and other immune diseases;
• shortness of breath; and
• skin symptoms.
Most of the recent reviews of the literature we examined generally
concurred with these Institute of Medicine conclusions as well, although a
few found a somewhat stronger relationship between indoor mold and
certain of the health effects listed above. For example, a 2007 review
concluded that dampness and exposure to indoor mold can exacerbate or
may cause shortness of breath, among other health effects.17 In addition,
other reviews differed in their conclusions regarding the link between
exposure to indoor mold and acute idiopathic pulmonary hemorrhage in
infants, the sudden onset of pulmonary hemorrhage in a previously healthy
infant. This condition was reported among a group of infants from the
same part of Cleveland, Ohio, in the 1990s and attributed by some
researchers to exposure to indoor mold. Five of the reviews we examined
contained conclusions about acute idiopathic pulmonary hemorrhage in
infants and children. Two concluded that mold has not been proven to
17J.M. Seltzer and M.J. Fedoruk, “Health Effects of Mold in Children,” Pediatric Clinics of
North America, vol. 54, no. 2 (2007).
Health Effects of Indoor Mold
cause this condition.18 However, a third review—the American Academy of
Pediatrics 2006 report—said that although a causal relationship has not
been firmly established, a variety of studies have provided some evidence
that such a relationship is plausible. The fourth review said that the
association between acute idiopathic pulmonary hemorrhage in infants
and children and mold is strong enough to justify removing them from
moldy environments or cleaning up these spaces,19 and the fifth review
reiterated this recommendation.20
Some of the health effects for which the evidence remains unclear (for
example, fatigue and acute idiopathic pulmonary hemorrhage in infants)
have been attributed to reactions to toxins, or “mycotoxins,” that can be
produced by certain types of mold that grow indoors. The reviews we
examined were largely consistent in their interpretations of the evidence
for the role of mycotoxins in relation to adverse health effects. The
Institute of Medicine reported in 2004 that (1) exposure to mycotoxins can
occur via inhalation, contact with the skin, and ingestion of contaminated
food and (2) research on Stachybotrys chartarum (a species of indoor
mold that can produce mycotoxins) suggests that effects in humans may
be biologically plausible. However, the report also noted that the effects of
chronic inhalation of mycotoxins require further study and that additional
research must confirm the observations on Stachybotrys chartarum
before a more definitive conclusion can be drawn. Among the more recent
reviews we examined that specifically addressed mycotoxins, five reached
a similar conclusion—that is, that the current evidence is inconclusive or
18A. Habiba, “Acute idiopathic pulmonary haemorrhage in infancy: Case report and review
of the literature,” Journal of Paediatrics and Child Health, vol. 41, no. 9-10 (2005); and
S.C. Susarla and L.L. Fan, “Diffuse alveolar hemorrhage syndromes in children,” Current
Opinion in Pediatrics, vol. 19, no. 3 (2007).
19T.G. Nuesslein, N. Teig, and C.H. Rieger, “Pulmonary haemosiderosis in infants and
children,” Paediatric Respiratory Reviews, vol. 7, no. 1 (2006).
20R.A. Etzel, “Indoor and outdoor air pollution: Tobacco smoke, moulds and diseases in
infants and children,” International Journal of Hygiene and Environmental Health, vol.
210, no. 5 (2007).
Health Effects of Indoor Mold
limited.21 However, one review suggested that it is likely that mycotoxins
play some role in building-related disease, including exacerbation of pre-
existing asthma.22 On the other hand, another recent review cast doubt on
the health effects of mycotoxins in one set of circumstances—specifically,
the review concluded that it was improbable for mycotoxins to cause
negative health effects through a toxic mechanism when individuals inhale
mycotoxins in nonoccupational settings (such as homes). This review,
however, explicitly stated this conclusion did not address adverse health
effects of mycotoxins that may be caused by immune-mediated
mechanisms or stem from exposure in occupational settings or by
ingestion.23
According to the 2004 Institute of Medicine report, two key issues largely
contribute to the scientific data gaps regarding the relationship between
mold and adverse health effects: (1) valid quantitative methods of
measuring exposure are lacking, and (2) a wide variety of potential
disease-causing agents are likely to be present in damp indoor
environments, which makes it difficult to link health effects with specific
agents. Without standardized, quantitative methods to measure exposure,
it is difficult to compare exposure levels across studies or between
individuals with and without symptoms of adverse health effects. This
makes it challenging to draw valid and consistent conclusions on the
health effects of indoor mold.
No single or standardized method to measure the magnitude of exposure
to mold has been developed. Consequently, researchers use a variety of
methods to assess exposure, each of which has advantages and
disadvantages. For example, most studies use an indirect method to assess
Two Key Factors Pose
Challenges for
Determining the Health
Effects of Exposure to
Indoor Mold
21In addition to the 2006 American Academy of Pediatrics review and Seltzer and Fedoruk
(2007), A.T. Borchers, C. Chang, C.L. Keen, and M.E. Gershwin, “Airborne Environmental
Injuries and Human Health,” Clinical Reviews in Allergy & Immunology, vol. 31, no. 1
(2006); K.-M. Lai, “Hazard Identification, Dose-Response and Environmental Characteristics
of Stachybotryotoxins and Other Health-Related Products from Stachybotrys,”
Environmental Technology, vol. 27, no. 3 (2006); and J.M. Portnoy, K. Kwak, P. Dowling, T.
VanOsdol, and C. Barnes, “Health effects of indoor fungi,” Annals of Allergy, Asthma &
Immunology, vol. 94, no. 3 (2005).
22B.B. Jarvis and J.D. Miller, “Mycotoxins as harmful indoor air contaminants,” Applied
Microbiology and Biotechnology, vol. 66, no. 4 (2005).
23R.K. Bush, J.M. Portnoy, A. Saxon, A.I. Terr, and R.A. Wood, “The medical effects of mold
exposure,” The Journal of Allergy and Clinical Immunology, vol. 117, no. 2 (2006).
Health Effects of Indoor Mold
exposure—occupant questionnaires about the presence of dampness or
mold in a building—according to the 2004 Institute of Medicine report.
Other exposure assessment methods include personal monitoring, which
involves measuring agent concentrations with monitors carried by
individuals, and quantifying biologic response markers in bodily fluids.
Another method of exposure assessment is to collect environmental
samples of indoor air, dust, or building materials such as wallboard and
quantitatively analyze the presence of mold (or its components or
products) in the samples. In addition to the various methods that can be
used to collect and analyze samples, environmental sampling for mold is
complicated by the fact that concentrations of mold (particularly in the
air) can vary over time and across an indoor environment. Moreover, many
newly developed sampling methods are not commercially available or
well-validated.
The second issue contributing to limitations in the understanding of the
relationship between mold and a number of adverse health effects is the
variety of potential disease-causing agents—including many species of
mold and other biological agents, such as bacteria or dust mites—that are
likely to be present in damp indoor environments. The number of such
agents makes it difficult to know which ones are specifically responsible
for the adverse health effects attributed to these environments. For
example, of the approximately 1 million species of mold, there are about
200 species of mold to which humans are routinely exposed, although not
all of these are commonly identified in indoor environments, and not all
types pose the same hazards to human health. The mold genus Alternaria,
for instance, which has been found in moldy building materials, has been
linked to severe asthma. Furthermore, several different components or
products of mold, such as mycotoxins, may function as disease-causing
agents in indoor environments. The release of these mold components or
products varies with environmental and other factors, and the individual
roles they may play in adverse health effects are not fully understood.
People are also exposed to mold in outdoor environments, where the
concentrations, while they vary considerably, are usually higher than those
found indoors. While the specific species of mold that grow indoors may
differ from those found outdoors, the potential for outdoor exposure
further complicates efforts to determine the relationship between adverse
health effects and indoor exposure to mold.
In addition to mold, damp indoor areas can support other biological agents
that may result in adverse health effects, including bacteria, dust mites,
cockroaches, and rodents. Dust mites, for example, are known to cause
the development of asthma. Damp conditions may also lead to potentially
Health Effects of Indoor Mold
harmful chemical emissions from building materials and furnishings. For
example, excessive indoor humidity may increase the release of
formaldehyde, a probable human carcinogen, from building materials such
as particle board. Exposure to formaldehyde has been linked to some of
the same health effects that have been attributed to indoor mold, such as
wheezing, coughing, and exacerbation of asthma symptoms, as well as
more severe effects.
The 2000 and 2004 Institute of Medicine reports and other recent reviews
of the scientific literature have identified numerous areas where further
research is required to advance the understanding of the relationships
between dampness, indoor mold, and human health.24 Specifically, the
health effects of the components and products of mold require further
study. The effects of mycotoxins in particular remain poorly understood,
partly because most of the toxicologic studies on mycotoxins have
examined the acute (or short-term) effects of high levels of exposure to
mycotoxins in small populations of animals. To address these limitations,
the 2004 Institute of Medicine report recommended that studies be
conducted to help determine, among other things, (1) the effects of
chronic (or long-term) exposures to mycotoxins via inhalation and (2) the
dose of mycotoxins required to cause adverse health effects in humans.
This report also recommended research on a particular species of toxin-
producing mold, Stachybotrys chartarum, and on the relationship
between mold and dampness and acute idiopathic pulmonary hemorrhage
in infants. In its 2000 report, the Institute of Medicine also called for
additional research related to mold particles as allergens and research to
evaluate the association of dampness and mold with the development of
asthma. As can be expected as research progresses over time, some of the
more recent reviews we examined made additional or more specific
research recommendations related to mycotoxins and other components
and products of mold. A number of lawsuits alleging serious health effects
as a result of exposure to indoor mold have involved exposure to
mycotoxins, underscoring the need for additional research in this area.
In addition, research to develop, improve, and standardize methods for
assessing exposure to mold is a high priority for understanding the health
Additional Research Is
Needed to Better Address
Uncertainties Related to
the Connection between
Health Effects and
Exposure to Indoor Mold
24Although our review focuses on the research needs directly related to indoor mold and
human health, the 2000 and 2004 Institute of Medicine reports identified a variety of other
research needs related to dampness, mold, and buildings.
Health Effects of Indoor Mold
effects of mold, according to the Institute of Medicine’s 2004 report.
Specifically, the report recommends additional research to validate and
refine existing exposure assessment methods for mold, including
procedures for collecting and analyzing environmental samples. Such
research would facilitate comparison of results within and across
epidemiological studies and help better define the relationships between
mold and adverse health effects. In addition, improved methods for
measuring exposure to specific components of mold would help efforts to
study the roles of these agents in causing adverse health effects.
The 2004 Institute of Medicine report also identified the need for
additional research on mold mitigation strategies and measures to prevent
or reduce dampness, the growth of indoor mold, and exposure to mold.
These strategies could include remediation activities, building renovation,
and changes in building operation or maintenance practices. For example,
research is needed to develop standardized, effective cleanup methods to
mitigate mold growth after flooding and other catastrophic water events.
In addition, the 2004 Institute of Medicine report recommended research
to assess how effectively personal protective equipment, such as gloves,
safety goggles, and respirators, reduces exposure to mold during
mitigation activities.25 Research in these areas is important to help ensure
that (1) mold mitigation actually improves unhealthy conditions in indoor
environments and (2) protective equipment used during remediation
successfully reduces the amount of mold to which workers and building
occupants are exposed.
25Other methods to protect building occupants and workers may involve containment
efforts to control the dispersal of mold through the building during remediation, which can
disturb building materials and release mold (particularly its spores) into the air.
Health Effects of Indoor Mold
Federal research activities address gaps in scientific data on the health
effects of indoor mold identified by the Institute of Medicine to varying
degrees, with a large number focusing on two areas in particular—asthma
and measurement methods. The impact of this research portfolio may be
reduced, however, by limited planning and coordination.
EPA, HHS, and HUD officials reported that they were conducting or
sponsoring 65 mold research activities as of October 1, 2007: HHS reported
43 ongoing research activities; and EPA and HUD reported 15 and 7,
respectively. The Institute of Medicine’s 2000 and 2004 reports identified a
number of gaps in the research needed to more clearly delineate any
association between exposure to indoor mold and a number of adverse
health effects.26 As shown in appendix III, these gaps may be grouped into
15 broad categories.27 Agency officials reported that most of the individual
federal research activities address 2 or more of the 15 data gaps.
Collectively, the agencies indicated that their research activities address
all of the 15 data gaps to varying extents—the number of research
activities addressing individual gaps ranged from 1 to 32 (see app. III).
Moreover, EPA, HHS, and HUD officials reported that 75 percent of their
mold research activities address at least one of five particular data gaps—
three of which relate to asthma, and two of which relate to sampling and
measurement methods. These five data gaps are as follows:
Federal Research
Activities on the
Health Effects of
Indoor Mold Address
Data Gaps to Varying
Degrees; Limited
Planning and
Coordination of the
Activities May Reduce
Their Ability to Close
Data Gaps
Federal Research
Activities on Mold Largely
Address Asthma and
Measurement Methods
26Clearing the Air and Damp Indoor Spaces and Health.
27We aggregated the research needs on the health effects of exposure to indoor mold that
were identified in the 2000 and 2004 Institute of Medicine reports into 15 groups of related
needs.
Health Effects of Indoor Mold
• Identify environmental factors that either lead to the development of
asthma or precipitate symptoms in subjects who already have asthma
using good measures of fungal exposure.
• Determine the association of dampness problems with asthma
development and symptoms by researching the causative agents (e.g.,
molds, dust mite allergens) and documenting the relationship between
dampness and allergen exposure.
• Advance the understanding of specific bioaerosols (small airborne
particles) in relation to asthma by studying the epidemiology of building-
related asthma in problem buildings where there are excess chest
complaints among occupants in comparison to buildings where there are
not complaints; or provide exposure-response studies of many building
environments and populations.
• Improve sampling and exposure assessment methods for mold and its
components (for example, by conducting research that will lead to
standardization of protocols for sample collection, transport, and analysis
or developing or improving methods of personal airborne exposure
measurement, DNA-based technology, or assays for bioaerosols, etc.).
• Develop standardized metrics and protocols to assess the nature, severity,
and extent of dampness and effectiveness of specific measures for
dampness reduction.
Overall, agency officials reported that 38 of the ongoing projects—or
nearly 60 percent—address asthma. In this respect, the federal mold
research portfolio for EPA, HHS, and HUD, ongoing as of October 1, 2007,
appears to be weighted toward addressing research gaps identified in the
Institute of Medicine’s 2000 report, Clearing the Air: Asthma and Indoor
Air Exposures. The research activities federal officials reported as
addressing one or more of the asthma-related research gaps include
studies using animals. For example, one focuses on gestational exposure
in mice to mold extracts and the effect this exposure has on the
development of allergy or asthma in adult life; one assesses in mice the
relative allergenic potency of molds statistically more common in water-
damaged homes; and another is developing animal models (using mice and
rats) to evaluate the pulmonary inflammatory response to mold products
collected from indoor dust samples from buildings where people have
reported respiratory symptoms and from buildings with no reported health
Health Effects of Indoor Mold
complaints.28 Other asthma-related research activities are aimed, for
example, at better understanding the relationship between respiratory
symptoms and exposure to water-damaged homes in posthurricane New
Orleans and at evaluating the respiratory health of staff and students
attending schools that expose them to varying degrees of dampness.29
(Summaries of the 65 research activities conducted or sponsored by EPA,
HHS, and HUD are provided in a supplement to this report—see GAO-08-
984SP.)
Many of the projects that address asthma also address sampling and
measurement methods. Research that provides high-quality, consistent
methodologies for sampling and measuring mold is essential to progress in
evaluating the health effects of exposure to mold. For example, the
Institute of Medicine reported in 2004 that evidence of an association
between exposure to mold and 15 specific health effects is inadequate or
insufficient to permit a conclusion regarding the presence of an
association because of the insufficient quality, consistency, or statistical
power of the available studies. This report, Damp Indoor Spaces and
Health, identified the need for standardized metrics and protocols. The
Institute’s earlier 2000 report that focused on asthma had previously
identified the need to improve exposure assessment methods for mold.
Overall, EPA, HHS, and HUD reported 36 research activities that address
sampling and exposure assessment methods or standardized metrics and
protocols. While a number of the research activities address these
measurement methods as part of investigations focusing on specific health
effects or other issues related to indoor mold, several focus solely or
primarily on developing measurement methods. For example, HHS’s
NIOSH is working to develop biomarkers of mold exposure to lead to
objective, standardized measures of exposure to support reproducible and
comparable analyses in health studies, including large-scale
epidemiological studies.30 HHS’s National Institute of Environmental
28These studies are titled “The Effect of Gestational Exposure to Mold on Allergy Induction
in a Mouse Model,” “Study of Putative Asthmagenic Molds,” and “Development of an
Animal Model to Evaluate the Contribution of the Fungal Product, ß-glucan, on the
Pulmonary Inflammatory Potential of Indoor Dust Samples.”
29These studies are titled “Health Effects of Exposure to Water-Damaged New Orleans
Homes Six Months After Hurricanes Katrina and Rita” and “Building-Related Asthma
Research in Maine Public Schools.”
30This research activity is titled “The Development of Monoclonal Antibody-Based
Immunodiagnostics for Fungal Hemolysins as Potential Biomarkers of Fungal Exposure.”
Health Effects of Indoor Mold
Health Sciences has three separate studies: (1) evaluating available
biomarkers of exposure and effect for specific molds that may cause
systemic toxicity, (2) developing tests for allergenic mold species and
toxin-producing molds found in water-damaged homes that can be used to
objectively assess mold exposure in buildings, and (3) testing the
feasibility of a flexible and low-cost measurement method for allergens,
including mold.31 Another example of ongoing research focusing on mold
identification is HHS’s CDC work to develop and validate DNA-based
methods for identification and fingerprinting medically important molds
because “the absence of a robust species/strain identification scheme has
hampered the rapid identification of novel species and the associated
burden of disease.”32
EPA and HUD also reported working on DNA-based assessment methods.
Specifically, agency officials reported ongoing work using, in part, a DNA-
based method for analyzing 36 species of mold that EPA developed,
patented, and has licensed commercial laboratories to perform. Working
with HUD, EPA used this method to develop a standard sampling and
analytic process that then led to the development of the Environmental
Relative Moldiness Index (ERMI) scale for U.S. homes. According to EPA,
this index provides a simple, objective evaluation of the mold burden in a
home. EPA reported ongoing epidemiological studies using the ERMI scale
aimed at determining if the ERMI values can be used to understand the
risk of asthma or related respiratory symptoms.33
While most of the 65 ongoing research activities involving indoor mold are
addressing asthma and critical data gaps in sampling and measurement
methods identified in the 2000 and 2004 Institute of Medicine reports,
31These studies are titled “Toxicology Studies of Mold Exposures,” “Fluorescent Multiplex
Array for Indoor Allergens (which is using enzyme immunoassay and multiplex array
technology),” and “Aptamer-Based Microarray for the Detection of Environmental
Allergens.”
32While HHS did not classify this ongoing research, “Study on Identification and Typing
(Fingerprinting) Medically Important Fungal Organisms Using DNA,” as meeting the data
gaps on sampling or measurement methods identified by the Institute of Medicine reports,
we believe that the information from this research activity has the potential to address
important measurement gaps.
33These research activities are titled “Study on Asthma and Environmental Factors, Which
Included an Application of the ERMI Index” and “Determining the National Distribution of
Selected Contaminants (Including Mold) in the Residential Environment (i.e., the American
Healthy Homes Survey).” The ERMI scale can describe the mold burden in any home on the
basis of its relative position compared with the entire U.S. housing stock.
Health Effects of Indoor Mold
some other important data gaps identified in the 2004 report are being
studied to a lesser degree than the gaps identified in the 2000 report.
Notably, of the 15 data gaps identified in these reports, agency officials
reported that only 9 research activities address to some extent 3 of the
gaps identified in the 2004 report that follow.34
• Research the relationship between mold and dampness and acute
pulmonary hemorrhage or hemosiderosis in infants.
• Determine the effects of human exposure to Stachybotrys chartarum in
indoor environments.
• Determine, for mycotoxins, the dose required to cause adverse health
effects in humans via inhalation and skin (dermal) exposure; techniques
for detecting and quantifying mycotoxins in tissues; or the effects of long-
term (chronic) exposures to mycotoxins via inhalation.
Officials from EPA, HHS, and HUD reported only one research activity
examining the relationship between mold and dampness and acute
pulmonary hemorrhage or hemosiderosis in infants—a rare but serious
health condition whose relation to exposure to indoor mold remains
unsettled, as discussed earlier. This research is aimed at developing
quantitative biomarkers for the toxin-producing mold species
Stachybotrys chartarum—a mold that has been implicated in cases of
acute pulmonary hemorrhage in infants—to facilitate epidemiological and
other studies examining mold-related health effects.35 Sponsored by HHS’s
National Institute of Environmental Health Sciences, this research will
support but does not directly address the 2004 Institute of Medicine’s
recommendation for research on the relationship between mold and
dampness and acute pulmonary hemorrhage in infants. Specifically, the
Institute of Medicine report concluded that the role of Stachybotrys
chartarum in cases of acute idiopathic pulmonary hemorrhage in infants
that had been studied remained controversial and encouraged HHS’s CDC
to pursue surveillance and additional research on the issue to resolve
outstanding questions because this condition has serious health
consequences. The Institute of Medicine further stated that epidemiologic
and case studies should take a broad-based approach to gather and
34One of the nine research activities is addressing two of the three data gaps to some
extent. To avoid double counting, this research activity is counted once.
35This study is titled “Study on Biomarkers for Exposure to Stachybotrys Chartarum.”
Health Effects of Indoor Mold
evaluate information on exposures and other factors that would help
identify the causes of acute idiopathic pulmonary hemorrhage in infants,
including dampness and agents associated with damp indoor
environments and environmental tobacco smoke, among others.
According to CDC officials, the agency is not currently conducting either
epidemiological or case studies on acute pulmonary hemorrhage in
infants.36
Five research activities that federal agencies reported were addressing the
toxin-producing mold species Stachybotrys chartarum were: part of two
studies on asthma; a study to develop tests for allergenic mold species and
toxin-producing molds found in water-damaged homes and a study to
develop quantitative biomarkers to assist epidemiological and other
research examining mold-related health effects (both discussed above as
also addressing other data gaps); and a follow-up study analyzing archived
serum and house dust samples for Stachybotrys chartarum and related
mycotoxins in the context of the clinical symptom profiles previously
gathered on the study participants.37
The research gap on the health effects of exposure to mycotoxins—toxins
that can be produced by certain types of mold and may potentially cause
adverse health effects—is being addressed to some extent by four
research activities, according to agency officials. One of the activities will
assess the potential for molds found in damp or water-damaged buildings
to cause nervous system or systemic toxicity. A second activity aims to
develop improved sensors for detecting mycotoxins in contaminated food
and feed to support proper remedial actions.38 A third activity is using an
animal model to understand the disease pathogenesis of hypersensitivity
36According to a CDC official, from January 2004 to June 2005, the agency undertook a
“chart review” of pulmonary hemorrhage designed to determine if existing computerized
information sources (such as hospital discharge and vital statistics data) or other
information could be used for national surveillance of acute pulmonary hemorrhage in
infants. After evaluating hospital records in six cities, CDC’s preliminary conclusions are
that national data sets are not reliable for this purpose and that local data sources should
be used instead.
37These studies are titled “Head-off Environmental Asthma in Louisiana,” “Relative Potency
of Mold Extraction in a Mouse Model,” “Fluorescent Multiplex Array for Indoor Allergens,”
“Study on Biomarkers for Exposure to Stachybotrys Chartarum,” and “Urban Moisture and
Mold Program-Continuation Project.”
38These activities are titled “Toxicology Studies of Mold Exposures” and “Allosteric
DNAzyme Sensors for Practical Detection of Mycotoxins.”
Health Effects of Indoor Mold
EPA reported
that while this study is not directed at mold per se, the secondary data
being collected could address some other research activities that the
Institute of Medicine reports identified as relating to sampling and
exposure assessment and mycotoxins, among others.
pneumonitis—a relatively rare but potentially serious allergic reaction in
susceptible persons that can, in its chronic form, result in permanent lung
damage.39 Lastly, a fourth activity is a study of the mechanistic indicators
of childhood asthma that uses air, biologic and clinical measures as well as
molecular biology, chemistry, and gene technologies to identify factors
that affect individual susceptibility to asthmatic responses.40
Finally, EPA and HHS reported they had completed 42 mold-related
research activities between January 1, 2005, and September 30, 2007.41 In
general, these activities address topics such as asthma and sampling and
measurement methods, reflected in the portfolio of agencies’ ongoing
research activities. Information on the recently completed research
activities is provided in a supplement to this report (see GAO-08-984SP).
While the information on research activities relating to the health effects
of exposure to indoor mold provides some insight into the extent to which
federal agencies are addressing scientific data gaps identified by the
Institute of Medicine in 2000 and 2004, the extent to which these ongoing
research activities will effectively advance scientific knowledge in these
areas is not clear. Specifically, the research is not guided by an
overarching strategic plan or entity that would help agencies work
together to identify their research priorities on the health effects of mold.
Instead, agencies generally determine independently which research
activities they will support using a variety of criteria. This lack of clearly
articulated, common research goals is exacerbated by the limited intra-
and inter-agency planning and coordination of research activities among
federal agencies. Specific information that highlights planning and
coordination limitations follows.
Selection criteria for research the agencies sponsor are not always
linked to identified data gaps. Several EPA, HHS, and HUD officials
Limited Planning and
Coordination of Research
Activities May Affect Their
Ability to Close Data Gaps
on the Health Effects of
Exposure to Indoor Mold
39This study is titled “The Role of Neutrophils in Hypersensitivity Pneumonitis.”
40This study is titled “Mechanistic Indicators of Childhood Asthma (MICA) Study.”
41HUD did not report any completed mold-related research activities during this time frame.
Health Effects of Indoor Mold
indicated that selection of priorities for research can be based on various
considerations, including agency expertise in a particular area or input
from external stakeholders. For example, both HHS and HUD officials
noted that ideas for research priorities can come from former grantees.
A key planning document that several EPA officials reported
consulting is now outdated. Specifically, the agency’s 2005 Program
Needs for Indoor Environments Research document,42 which outlines the
agency’s research needs for the indoor environment and mold, among
other topics, reflects input from the Institute of Medicine’s 2000 report but
not the more recent 2004 report, which also identified a number of
important data gaps. EPA officials told us that the agency’s research
related to asthma and mold’s health effects has been a priority, in part,
because this topic was identified in the 2000 Institute of Medicine report,
Clearing the Air: Asthma and Indoor Air Exposures.
Some officials stated that the 2004 Institute of Medicine report on
indoor mold has not influenced their research priorities on this
topic. While officials at HHS’s NIOSH reported that the Institute of
Medicine’s 2004 report had a “major impact” on what indoor
environmental quality research their institute conducts, HHS officials from
two of the National Institutes of Health noted that this report did not affect
their institutes’ internal priorities in this area. One official stated that while
the publication of this report did not change any of their internal priorities,
it may have encouraged external interest in mold research.
The process that NIH uses to fund outside research may also limit
the extent to which identified data gaps are addressed. Specifically,
federal officials from three different NIH institutes43 that sponsored 29 of
the 65 ongoing research activities as of October 1, 2007, reported that 19
were unsolicited—that is, they were initiated by investigators outside the
institutes.44 Most NIH-funded research is initiated by such investigators.
These investigators submitted research proposals that were of interest to
42EPA, Program Needs for Indoor Environments Research, EPA 402-B-05-001 (March
2005).
43These are the National Institute of Environmental Health Sciences; the National Heart,
Lung, and Blood Institute; and the National Institute of Allergy and Infectious Diseases.
44One of the 29 research activities was funded partly by an unsolicited grant and partly by a
solicited cooperative agreement. We considered this activity as both unsolicited and
solicited.
Health Effects of Indoor Mold
them and thus were not necessarily responsive to specific agency
priorities. Along these lines, officials at one institute said they generally
fund indoor mold research only because of outside investigators’ interest.
Unsolicited proposals are ranked for funding through a rigorous peer-
review process for, among other things, scientific merit and the
significance of the research.45 While the specific topic of the research is
considered in light of its potential impact on public health during peer
review, NIH officials said that specific gaps identified in the Institute of
Medicine’s report may well have a lower significance relative to the three
institutes’ many other scientific priorities. That is, while the three
institutes do solicit research on areas considered to be priorities, studies
on the health effects of exposure to indoor mold have generally not been
in this category.
Less than half of the agencies’ 65 ongoing research activities are
being coordinated, either within or outside their agencies.
Specifically, in responding to our survey of ongoing research activities
involving the health effects of indoor mold, EPA, HHS, and HUD reported
that 28 of their 65 research activities are being coordinated (see fig. 1). In
other work, we identified practices that agencies should use when
coordinating their activities, including (1) defining and articulating a
common outcome, (2) identifying and addressing needs by leveraging each
others’ resources, and (3) agreeing on agency roles and responsibilities.46
Especially when agencies are conducting research activities addressing
the same data gap, coordination is important to ensure inappropriate
duplication of efforts does not occur and to best leverage limited federal
resources. Even in these cases, however, a significant number of activities
are not being coordinated. For example, of the 32 EPA, HHS, and HUD
research activities seeking to identify which environmental factors, such
as mold, contribute to the development or exacerbation of asthma, federal
officials reported that 18 activities are not being coordinated. Similarly,
agencies are not coordinating on 22 of 36 research activities related to
sampling and measurement methods.
45An NIH official said that after the peer-review process is completed, proposals are given a
merit score, which is based on factors such as the qualifications of the researcher and the
level of innovation and significance of the research. Funding is then allocated to research
activities in priority order based on this ranking.
46GAO, Results-Oriented Government: Practices That Can Help Enhance and Sustain
Collaboration among Federal Agencies, GAO-06-15 (Washington, D.C.: Oct. 21, 2005).
Health Effects of Indoor Mold
Figure 1: Coordination of Ongoing Federal Mold Research Activities within the
Agency or among Other Federal Agencies, as of October 1, 2007
Note: HHS officials reported coordinating three research activities with external organizations only.
These activities are listed as not coordinated in this figure.
Further, the coordination activities reported by federal officials vary
widely. In some cases, the federal officials we surveyed reported internal
and external coordination on a specific research activity. For example, an
EPA official noted that his unit conducted one of its research activities in
conjunction with another unit within the agency, provided updates
regarding the activity to another unit, and collaborated with another
federal agency to write papers based on this research. Coordination was
more limited in other cases. Specifically, in many cases, research activities
were only coordinated within the agency—and often, with only one other
unit within the agency. For example, one NIOSH official reported that, for
one activity, his unit coordinated with another unit within NIOSH by
supplying certain instruments.
Importantly, while agencies sometimes coordinate on individual research
activities, we did not identify any sustained efforts to coordinate agencies’
05101520253035404550HUDHHSEPANumber of activites reportedFederal agenciesResearch activities coordinated to some extentResearch activities not coordinatedSource: GAO analysis of EPA, HHS, and HUD survey data.
Health Effects of Indoor Mold
indoor mold research priorities. In the few instances in which officials
reported that they coordinated with others on research priorities, it
appeared that these partnerships did not specifically address mold-related
priorities. For example, while EPA officials told us that they recently met
with officials from HHS’s CDC to discuss mutual research opportunities
related to the indoor environment, these meetings did not address mold
research priorities.
Federal agencies are not using the existing Federal Interagency
Committee on Indoor Air Quality as a forum to coordinate their
research activities on indoor mold. As discussed earlier, EPA serves as
the executive secretary of the Federal Interagency Committee on Indoor
Air Quality. We found that the committee addresses federal research
activities on indoor air quality on an informal basis. For example, our
analysis of the minutes of the 11 committee meetings from February 2005
to February 2008 shows that agency priorities related to indoor air quality
research, which could include research on mold, were discussed only a
few times. In one case, EPA officials described how their agency had
developed its research needs on indoor environments, which it published
in a document later in 2005 titled Program Needs for Indoor
Environments Research. In this case, EPA was not seeking input from
other agencies on research needs and priorities but rather was informing
other agencies of decisions EPA had made. Moreover, EPA, HHS, and
HUD officials who participate in committee meetings told us that they had
not discussed or sought input on their agency’s mold-related research
priorities during committee meetings. Further, according to committee
meeting minutes, the information agency officials share at committee
meetings regarding their mold research is limited to describing selected
ongoing activities and issues related to their funding. When mold-related
research was discussed during the 3-year period we reviewed, it was
usually to provide an update on the status of some individual research
projects. In several instances, officials also used the meetings to advertise
the availability of funding for research on indoor air quality issues, which
could include research on mold, or to announce the funding of mold-
related research.
Currently, the committee holds 2-1/2 hour meetings in person and by
conference call three times a year that interested parties outside the
federal government can access. The agendas for the meetings are based on
input to EPA from member and nonmember agencies who propose topics
they would like to discuss. According to officials from one of the
participating agencies, the Consumer Product Safety Commission, the
Federal Interagency Committee on Indoor Air Quality had more
Health Effects of Indoor Mold
substantive discussions in the past on research projects, funding, and
which research priorities needed to be addressed than it does now.
The role of the Federal Interagency Committee on Indoor Air Quality has
changed over time. Established in response to congressional committee
direction in 1983, the committee, according to an EPA report,47 was to (1)
coordinate federal indoor air quality research; (2) provide for liaison and
the exchange of information on indoor air quality research among federal
agencies, and with state and local governments, the private sector, the
general public, and the research community; and (3) develop federal
responses to indoor air quality issues. According to a 1988 report on the
structure and operation of the committee, the committee comprised 16
member agencies and was co-chaired by EPA, the Consumer Product
Safety Commission, DOE, and HHS. This report noted that considerable
agreement existed among member agencies that the primary role of the
committee was to coordinate federal indoor air activities. Further,
coordination activities were specified to include joint project planning and
implementation; contributions to and review of member agency indoor
plans, reports, and publications; communication on technical and
nontechnical issues and activities; and advising on, and fostering
multiagency participation in, indoor air program and research activities of
individual agencies. The committee met quarterly and had standing work
groups covering indoor air quality research areas to address a diverse
range of indoor air quality research issues, such as radon, formaldehyde,
and allergens and pathogens (which include molds). The work groups,
which are no longer active, were to coordinate research activities in these
areas and identify future indoor air quality research. EPA used the
committee to coordinate air quality research and assist in implementing
the indoor air quality research and development program established by
Congress in 1986. For example, in 1989 and 1999, EPA used the committee
to help it develop two reports that identified the individual research
activities on indoor air quality that federal agencies were conducting. EPA
has taken the lead in directing committee activities in the past, such as
chairing meetings, and this role continues today.
47EPA, Report to Congress on Indoor Air Quality: Volume I: Federal Programs
Addressing Indoor Air Quality, EPA/400/1-89/001B (August 1989).
Health Effects of Indoor Mold
The Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD
guidance documents we reviewed identify health effects associated with
indoor mold in a residential setting but sometimes omit less common but
serious health effects. Most of the guidance documents recommend
similar strategies for minimizing mold growth. While guidance documents
that discuss mold mitigation offer consistent advice about detecting mold,
some provide conflicting information about cleaning agents and the
appropriate level of protective equipment individuals need when
mitigating mold in their homes.
A majority of the 32 documents we reviewed that provide guidance to the
general public on the health effects of indoor mold in their homes—issued
by the Consumer Product Safety Commission, EPA, FEMA, HHS,48 and
HUD—identify asthma and upper respiratory tract symptoms as potential
health effects. In addition, many of these federal guidance documents cite
unspecified allergic symptoms and skin symptoms, such as dermatitis,
rashes, and hives. The six adverse health effects the Institute of Medicine
found to be associated with indoor mold in 2004 are included in the 32
guidance documents to varying extents. However, all six adverse health
effects are included in only two guidance documents, although a majority
of the guidance was issued after the publication of the 2004 Institute of
Medicine report.49
Further, only a few of the 32 guidance documents discuss adverse health
effects associated with mold that are less common but serious. Such
health effects include opportunistic infections or fungal colonization in
immune-compromised individuals and hypersensitivity pneumonitis, a
relatively rare allergic reaction in susceptible persons characterized by
Federal Guidance to
the General Public
Identifies Various
Health Effects
Associated with
Exposure to Indoor
Mold, as well as
Strategies to Limit It,
Some of Which Are
Inconsistent
Federal Guidance Cites
Various Adverse Health
Effects of Exposure to
Indoor Mold but in Some
Cases Omits Less Common
but Serious Effects
48All the HHS guidance documents we reviewed were issued by CDC.
49The six adverse health effects identified by the Institute of Medicine are the exacerbation
of asthma symptoms, upper respiratory tract symptoms, cough, wheeze, hypersensitivity
pneumonitis, and opportunistic infections and fungal colonization in immune-compromised
individuals.
Health Effects of Indoor Mold
fever, chills, dry cough, and a flulike feeling that can, in its chronic form,
result in permanent lung damage. Because these less common but
potentially serious adverse health effects are infrequently cited in the
guidance documents, some individuals consulting these guidance
documents may not take appropriate precautions when they are exposed
to indoor mold. Table 1 identifies the potential adverse health effects cited
in 6 or more of the 32 guidance documents we reviewed. (App. V provides
a list of the guidance documents we reviewed and information on how to
access them.)
Table 1: Potential Adverse Health Effects of Exposure to Indoor Mold Cited in Six or More Guidance Documents, by Federal
Agency
Number of documents reviewed, by agency
Potential adverse health effects of
exposure to indoor mold
CPSCa (2)
EPA (12)
FEMA (8)
HHS (6)
HUD (6)
Total number of
documents citing
the health effects
Number of documents citing the health effects
Asthma, asthma triggers, or asthma
symptoms (such as episodes or
attacks)
2
11
6
4
6
27b
Upper respiratory tract symptomsc
2
4
6
6
5
21b
Eye symptomsd
2
3
6
6
5
20b
Skin symptomse
1
2
5
5
4
16b
Allergies or allergic reactions
(symptoms not otherwise specified)
0
7
4
3
1
15
Wheeze
1
1
5
5
2
13b
Cough
2
2
4
2
2
10b
Difficulty breathing or trouble
breathing
1
1
3
2
4
10b
Infections (including those affecting
people who have chronic lung
disease)
0
1
3
6
0
10
Adverse effects to the nervous
systemf
1
1
3
0
4
8b
Shortness of breath
1
1
3
3
0
7b
Fungal colonization or opportunistic
infections in immune-compromised
individuals
0
1
0
5
1
6b
Hypersensitivity pneumonitis
1
4
0
2
1
6b
Source: GAO analysis of selected federal guidance.
Health Effects of Indoor Mold
Notes: Other health effects stemming from exposure to indoor mold, including fatigue, fever,
dizziness, and gastrointestinal tract problems, are cited in five or fewer guidance documents. Health
effects of exposure to indoor mold that are cited in only one document include aches and pains, lung
irritation, and death.
aConsumer Product Safety Commission.
bThe sum of the guidance documents does not equal the total number of guidance documents citing
the health effect because two documents, “Healthy Indoor Air for America’s Homes” and “The Inside
Story: A Guide to Indoor Air Quality,” were issued by multiple federal agencies.
cSymptoms can include nasal congestion, sneezing, runny/itchy/stuffed up nose, throat irritation, and
sore throat.
dSymptoms can include redness, watery eyes, irritation, and burning.
eSymptoms can include dermatitis, itching, rashes, hives, and irritation.
fSymptoms can include headaches, memory loss, and mood changes.
Moreover, most of the federal guidance documents we reviewed describe
populations that may be particularly sensitive to indoor mold. However,
few of the documents identify all of the populations that should take extra
precautions to limit exposure to indoor mold. According to an HHS
guidance document, these populations include the immune-compromised
as well as those with asthma, chronic lung diseases, and allergies to mold.
Immune-compromised individuals include organ transplant recipients, HIV
patients, individuals with leukemia or lymphoma, and those undergoing
cancer chemotherapy or other immunosuppressant drug therapies. HHS
also recommends “due caution” for children, pregnant women, and the
elderly who are exposed to indoor mold. Although some of the guidance
documents identify several of these populations, some list only one or two.
As a result, individuals consulting these guidance documents, especially
those who are particularly vulnerable to mold exposure, may not be fully
apprised of the risks associated with such exposure.
We recognize that the guidance documents we reviewed may address
health effects and particularly sensitive populations in varying levels of
detail because of differences in purpose and intended audience. For
example, several EPA guidance documents targeted toward particular
populations, such as teens, the elderly, and people with low literacy levels,
are limited in their scope and level of detail. In contrast, HHS’s document,
Mold Prevention Strategies and Possible Health Effects in the Aftermath
Health Effects of Indoor Mold
of Hurricanes and Major Floods,50 which is targeted to the general public
as well as to public health officials, includes a detailed discussion of
numerous potential health effects that may result from exposure to indoor
mold. Although not all guidance documents need to provide a
comprehensive list of all of the potential health effects of exposure to
indoor mold, the information provided should be sufficient to alert the
public about potential adverse health effects of exposure to indoor mold,
highlight specific populations that are particularly vulnerable to such
exposure, and not conflict among documents.
Guidance on Minimizing
Indoor Mold Growth in
Homes Is Generally
Consistent
Most of the 32 guidance documents issued by the Consumer Product
Safety Commission, EPA, FEMA, HHS, and HUD that we reviewed
describe how to minimize indoor mold growth in the home. These
documents generally advise that residents reduce indoor moisture or
humidity levels, and their recommendations for doing so are generally
consistent. A majority of these guidance documents recommend that
residents keep areas dry and address moisture sources, such as leaks or
spills. Some of the guidance documents also recommend managing
specific sources of moisture or humidity by, for example, preventing water
from entering the house, ventilating and cleaning kitchens and baths to
reduce moisture buildup, and repairing and insulating pipes. In addition, a
majority of the documents recommend promptly drying wet items. Nearly
half of the documents that provide more specific recommendations note
that porous items, such as carpets, must be dried within 48 hours to avoid
the growth of mold and say that if more than 48 hours have elapsed, these
items should be discarded.
A number of the guidance documents that address strategies to minimize
indoor mold growth also advise residents to maintain indoor relative
humidity within specific ranges because high relative humidity can lead to
water condensation on indoor surfaces, such as walls and windows, which
can support mold growth. However, we note that the humidity ranges
specified by the guidance documents vary. For example, while all the
guidance documents that address relative humidity recommend
maintaining it at 60 percent or below, one FEMA document recommends
maintaining the relative humidity below 40 percent, and three guidance
50Department of Health and Human Services, Centers for Disease Control and Prevention,
Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes
and Major Floods (Atlanta, 2006).
Health Effects of Indoor Mold
documents issued by HHS recommend a relative humidity range between
40 percent and 60 percent.51 Such differences in guidance to the public
could cause some confusion about this aspect of minimizing indoor mold
growth.
Guidance on Mitigating
Exposure to Indoor Mold
Is Sometimes Inconsistent
about Cleanup Agents and
Protective Clothing and
Equipment
A majority of the guidance documents we reviewed provide information to
the public about mitigating exposure to indoor mold. Many of the
documents agree that if mold can be either seen or smelled, it should be
removed. Recommendations on detecting mold are broadly consistent
with information in a 2001 EPA report on mold mitigation in schools and
commercial buildings, which is cited by a number of the guidance
documents as a resource for mitigation of residential mold growth.52,53
Further, the eight guidance documents that discuss sampling or testing to
measure the quantity or type of mold in the indoor environment advise
against it in most circumstances because the results of such testing may
not be useful. For example, one of these documents explains that no
standardized method exists either to measure the magnitude of exposure
to mold or to relate a particular level of exposure to adverse health effects.
Another guidance document notes that it is generally not necessary to
determine the species of mold present.54 Finally, many of the guidance
documents that discuss mitigation note that if the mold is extensive (for
example, if it covers more than 25 square feet) or if it is found in the
heating or air conditioning systems, residents should consult further
guidance, such as EPA’s Mold Remediation in Schools and Commercial
Buildings, or hire a professional contractor.
51Department of Homeland Security, Federal Emergency Management Agency, Dealing
with Mold and Mildew in Your Flood Damaged Home (Washington, D.C., 2005).
Department of Health and Human Services, Centers for Disease Control and Prevention,
Mold Questions and Answers: Questions and Answers on Stachybotrys chartarum and
other molds (Atlanta, 2004); Facts About Mold And Dampness (Atlanta, 2005); and Molds
in the Environment (Atlanta, 2005).
52EPA, Mold Remediation in Schools and Commercial Buildings (Washington, D.C., June
2001).
53Guidance documents typically referred readers to this report if mold removal exceeds 10
square feet, although it also addresses mold cleanups of less than 10 square feet.
54As discussed earlier in this report, however, litigants attempting to show that exposure to
indoor mold has resulted in adverse health effects generally need to demonstrate to courts
that a specific species of mold caused a specific adverse health outcome.
Health Effects of Indoor Mold
While a majority of the guidance documents we reviewed discuss how to
remove mold once a problem has been identified, there is some
inconsistency about which cleaning agents to use. For example, two
guidance documents recommend using detergent to clean mold. On the
other hand, HHS’s Mold Prevention Strategies and Possible Health Effects
in the Aftermath of Hurricanes and Major Floods advises that bleach
may be warranted if the mold growth is due to floodwater, which can be
contaminated. Another guidance document, issued by EPA, also advises
that bleach be used when individuals who are particularly susceptible to
adverse health effects from mold, such as those who are immune-
compromised, are exposed to indoor mold. In contrast, six of the guidance
documents we reviewed, including several of the HHS documents,
recommend the use of bleach irrespective of certain populations or
whether the mold growth is due to flooding. According to EPA’s 2001
report on mold mitigation, mold growing on hard (nonporous) surfaces
should be scrubbed with water and detergent and then vacuumed.55 This
report recommends using bleach only in limited circumstances—such as
when immune-compromised individuals are present—because bleach, a
biocide, is toxic to humans. These differences among guidance documents
could lead to confusion among the general public about the safest and
most effective way to remove mold. For example, if bleach is not
necessary in most instances, using it unnecessarily could lead to avoidable
problems, since bleach itself is a hazardous substance that can generate
toxic fumes if it is mixed with ammonia-based cleaners.
In addition, many of the guidance documents we reviewed discuss using
personal protective equipment while removing mold but, in some cases,
recommend different levels of protection for the general public as well as
for certain populations that may be more sensitive to mold exposure. For
example, as figure 2 shows, the guidance documents provide inconsistent
recommendations for the general public about wearing respiratory
protection, eye protection, and skin (dermal) protection (such as long-
sleeved shirts and long pants) for cleanups of limited mold
contamination.56
55EPA, Mold Remediation.
56The smallest areas addressed by guidance documents we reviewed vary from up to 10
square feet to up to 100 square feet.
Health Effects of Indoor Mold
Figure 2: Varying Levels of Personal Protection for Cleaning Limited Mold Contamination, as Recommended by Selected
Federal Guidance
Source: GAO analysis of selected federal guidance.
Recommended by
three guidance
documents:
• gloves
• respiratory
protectionRecommended by six
guidance documents:
• gloves
• respiratory
protection
• eye protectionRecommended by
six guidance
documents:
• gloves
• respiratory
protection
• eye protection
• dermal protection
Note: The guidance variously defines “limited” mold contamination as areas ranging from up to 10
square feet to up to 100 square feet.
In addition, although 26 guidance documents caution that certain
populations may be more sensitive to mold, only 2 of them, issued by HHS
in 2005 and 2006, provide specific recommendations about the varying
levels of personal protection that such populations should use under
various circumstances. The HHS documents state that, when inspecting or
assessing damage, individuals with certain lung diseases should wear
respirators, while healthy individuals need no special protection for these
tasks. However, these documents warn that individuals with
“immunosuppression,” such as those undergoing cancer treatment or
those who have leukemia or lymphoma, should wear a respirator, gloves,
and safety goggles when inspecting or assessing damage. Further, those
with “profound immunosuppression”—such as those with HIV infection—
should avoid all exposure to mold.
Health Effects of Indoor Mold
Guidance documents also provide inconsistent information about the
types of respiratory protection to use when cleaning up mold. Of the 15
guidance documents that recommend the use of respiratory protection
during cleanup, 6 list items such as dust masks, which do not protect
against mold because it can pass through them. Nine of the documents
suggest “N-95 respirators,” which filter 95 percent of airborne particles and
can protect against inhaling mold. Moreover, only 3 of the guidance
documents recommending the use of N-95 respirators discuss the need for
proper fit—which could impact their effectiveness, according to the HHS’s
NIOSH, the federal agency that approves these respirators. Furthermore,
only 1 guidance document, issued by HHS, warns that respirator use may
not be appropriate if an individual has a pre-existing medical condition
that makes it difficult to breathe while wearing a respirator.
A number of agency officials said they revisit the content of their guidance
documents following significant new scientific discoveries or in response
to events such as major flooding or hurricanes. We note that in the past
few years, important updated information on the health effects of
exposure to indoor mold and ways to protect against unnecessary
exposure has been provided in three documents: the Institute of
Medicine’s 2004 report and two HHS guidance documents on mold issued
in 2005 and 2006 in the aftermath of the hurricanes and major floods on
the Gulf Coast.57 Nevertheless, some of the guidance documents we
reviewed do not yet reflect important updated information that these
publications provide. Overall, despite the useful information provided in
the federal guidance we reviewed, some omissions and inconsistencies
could cause some individuals to be exposed to indoor mold unnecessarily.
Conclusions
While the current research activities on indoor mold conducted or
sponsored by EPA, HHS, and HUD address identified health-related
research gaps to varying degrees, these activities are largely
uncoordinated within and across agencies, and many are generated by
independent researchers rather than by agency solicitations for specific
research. This limited coordination contributes to the lack of standardized,
quantitative methods for measuring exposure to mold that has impeded
57Department of Health and Human Services, Centers for Disease Control and Prevention,
Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes
and Major Floods (Atlanta, 2006) and Population-Specific Recommendations for
Protection From Exposure to Mold in Buildings Flooded After Hurricanes Katrina and
Rita, by Specific Activity and Risk Factor (Atlanta, 2005).
Health Effects of Indoor Mold
the advancement of knowledge about health effects and may result in
unnecessary duplication of research efforts. Without more systematic
coordination of planned and ongoing research activities, future research
may not be prioritized to best fill data gaps or be of sufficient quality and
consistency to more definitively support conclusions about any
associations to indoor mold and adverse health effects. Specifically, the
Institute of Medicine was unable to associate a number of adverse health
effects with exposure to mold because the available studies were of
“insufficient quality, consistency, or statistical power to permit a
conclusion regarding the presence of an association.”
An existing interagency committee—the Federal Interagency Committee
on Indoor Air Quality—could provide an effective vehicle for enhancing
the coordination of research activities. As the executive secretary and co-
chair, EPA guides the activities of this committee, which was established
in response to congressional direction to, among other things, coordinate
federal indoor air quality research and foster information sharing among,
for example, federal agencies and the public. While the committee
provides a forum for informal information sharing, it has not been used in
recent years to support systematic coordination of federal research
priorities or agendas for indoor air research. Since the Federal Interagency
Committee on Indoor Air Quality was established in the 1980s, significant
advances in communications technologies, such as the Internet, have
transformed the exchange of information—for example, through Web
pages and hyperlinks to documents and Web sites. These communications
advances can facilitate the coordination among federal agencies, state and
local governments, the private sector, the research community, and the
general public that the Federal Interagency Committee on Indoor Air
Quality was established to accomplish.
Overall, the federal guidance documents we reviewed that provide
information to the general public about the health effects of exposure to
indoor mold, ways to minimize mold growth, and safe and effective
methods for cleaning up provide generally useful information. However,
some documents do not sufficiently advise the general public about some
potentially serious health effects, and others provide inconsistent
information about cleaning agents and appropriate protective gear.
Regarding protective gear, some documents do not provide information
about how populations that are particularly vulnerable to adverse health
effects should protect themselves. In fact, populations with certain
immunosuppression conditions should avoid exposure to mold but many
guidance documents do not state this. As a result, the public may not be
sufficiently aware of the health risks they or their family members may
Health Effects of Indoor Mold
face, and they may also be confused about how to approach cleaning up
mold in their homes.
Recommendations for
Executive Action
We recommend that the Administrator, EPA, use the Federal Interagency
Committee on Indoor Air Quality to accomplish the following two actions.
• Help articulate and guide research priorities on indoor mold across
relevant federal agencies, coordinate information sharing on ongoing and
planned research activities among agencies, and provide information to
the public on ongoing research activities to better ensure that federal
research on the health effects of exposure to indoor mold is effectively
addressing research needs and efficiently using scarce federal resources.
• Help relevant agencies review their existing guidance to the public on
indoor mold—considering the audience and purpose of the guidance
documents—to better ensure that it sufficiently alerts the public,
especially vulnerable populations, about the potential adverse health
effects of exposure to indoor mold and educates them on how to minimize
exposure in homes. The reviews should take into account the best
available information and ensure that the guidance does not conflict
among agencies.
We provided the Consumer Product Safety Commission, EPA, FEMA,
HHS, and HUD with a draft of this report and the related supplement
(GAO-08-984SP) for the agencies’ review and comment. In its response,
EPA generally agreed with our recommendations that it use the Federal
Interagency Committee on Indoor Air Quality to, among other things, help
articulate and guide research priorities on indoor mold across relevant
federal agencies and help relevant agencies review their existing guidance
to the public on indoor mold to better ensure that it sufficiently alerts the
public about the potential adverse health effects of exposure to indoor
mold and educates the public on how to minimize exposure in homes. In
commenting on the draft report, HUD and the Consumer Product Safety
Commission also generally supported our recommendations to EPA.
FEMA did not provide comments on the report, and HHS’s comments did
not address our recommendations to EPA. The Consumer Product Safety
Commission, EPA, HHS, and HUD also provided technical comments on
our report, and HHS provided a technical comment on the supplement;
their comments were incorporated, as appropriate.
Agency Comments
and Our Evaluation
Health Effects of Indoor Mold
As agreed with your office, unless you publicly announce the contents of
this report earlier, we plan no further distribution until 30 days from the
report date. At that time, we will send copies to the Acting Chairman,
Consumer Product Safety Commission; Administrator, EPA;
Administrator, FEMA; Secretary, HHS; Secretary, HUD; and other
interested parties. We will also make copies available to others upon
request. In addition, the report will be available at no charge on the GAO
Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me
at (202) 512-3841 or
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Contact points for our Offices
of Congressional Relations and Public Affairs may be found on the last
page of this report. GAO staff who made major contributions to this report
are listed in appendix VI.
Sincerely yours,
John B. Stephenson
Director, Natural Resources
and Environment
Health Effects of Indoor Mold
The objective of this review was to assess federal agencies’ activities to
minimize and mitigate the health effects of exposure to indoor mold.
Specifically, we examined (1) what recent reviews of the scientific
literature have concluded about the health effects of exposure to indoor
mold; (2) the extent to which federal research addresses data gaps related
to the health effects of exposure to indoor mold; and (3) what guidance
key federal agencies are providing to the public on the health risks of
exposure to mold, and on minimizing and mitigating that exposure, and
the extent to which the guidance is consistent. Our review focuses on the
health effects and guidance to the general public related to indoor mold in
homes and does not address occupational exposures or technical guidance
documents targeted to specialized audiences, such as medical
professionals and emergency response workers.
To determine what recent reviews of the scientific literature have
concluded about the health effects of exposure to indoor mold, we
primarily relied on the findings in the National Academies’ Institute of
Medicine comprehensive report issued in 2004, Damp Indoor Spaces and
Health. To identify more recent reviews of the health effects of exposure
to indoor mold, we conducted a literature search. We searched for reviews
and meta-analyses, rather than individual studies, published in English in
2005, 2006, and 2007, primarily using PubMed, a bibliographic database
service of the U.S. National Library of Medicine. We conducted 19
different searches of PubMed using combinations of the following search
terms: mold, exposure, health, indoor, glucan, microbial volatile organic
compounds, mycotoxins, ergosterol, hemolysins, fungal extracellular
polysaccharides, fungal/hyphal fragments, allergens, stachybotrys, acute
ideopathic pulmonary hemorrhage, acute pulmonary hemorrhage and
infants, and hemosiderosis. As part of these searches, we used PubMed’s
Clinical Queries option to find Systematic Reviews, which cover a broad
set of articles that build consensus on biomedical topics. We also
conducted a search for reviews and meta-analyses using the search
strategy “mold AND (exposure OR indoor OR health)” in 15 other
databases providing comprehensive worldwide coverage of scientific and
technical journals on relevant topics. We reviewed the abstracts of all
search results and obtained copies of the publications for which no
abstracts were available, unless the available information indicated that
the publication was unrelated to our review. We evaluated the relevance of
the abstracts and publications and identified those that addressed the
health effects of exposure to indoor mold and its constituents or products,
excluding those that addressed dietary exposures, exposures in industrial
or agricultural settings, publications focused on yeasts, case studies of
mold in particular locations, and any publications that were clearly not
Appendix I: Objectives, Scope, and
Methodology
Appendix I: Objectives, Scope, and
Methodology
Health Effects of Indoor Mold
meta-analyses or reviews of the scientific literature. Twenty of the reviews
met our criteria (see app. II for a list of these reviews). To assess the
credibility, reliability, and methodological soundness of these
publications, a senior GAO analyst with a doctorate in epidemiology
reviewed each of the publications and any additional methodological
information obtained from the authors and considered such factors as the
bibliographies of evidence cited, the journals in which the articles were
published, and the extent to which they are primary authors of other
relevant articles. We did not examine the references cited by these studies
as part of our analysis. Some of the reviews may be based on primary
sources (for example, epidemiologic studies), while others may also be
based on sources that are themselves reviews of the scientific literature
(for example, the 2004 Institute of Medicine report). We concluded that all
20 reviews were sufficiently reliable for the purposes of this report.
We also used the 2004 Institute of Medicine report to help identify areas
where additional research is needed to address scientific data gaps
primarily related to the health effects of exposure to indoor mold other
than asthma, as well as the institute’s 2000 report, Clearing the Air:
Asthma and Indoor Air Exposures, which focused on gaps related to
asthma. We conducted in-depth reviews of these reports, including their
methodology and conclusions, and we summarized the research needs
they identified related to the health effects of exposure to indoor mold.
To obtain information on federal research related to the health effects of
exposure to indoor mold, we conducted two surveys of officials at the
Environmental Protection Agency (EPA), the Department of Health and
Human Services (HHS), and the Department of Housing and Urban
Development (HUD) from November 2007 to May 2008. We used one
survey to (1) identify research activities related to the health effects of
indoor mold ongoing as of October 1, 2007, and (2) determine the extent to
which these research activities address the 15 data gaps identified in the
2000 and 2004 Institute of Medicine reports related to the health effects of
exposure to indoor mold. Respondents completed a survey for each
individual research activity ongoing as of October 1, 2007. We also used
this survey to identify the extent to which these activities were
coordinated both within and across agencies. We conducted a second
survey of these agencies to collect basic information on their mold-related
research activities completed from January 1, 2005, to September 30, 2007.
Overall, we received information on 107 research activities from 37 EPA,
HHS, and HUD officials. We received responses to our surveys from all
relevant officials and agency entities. Summaries of the research activities
Health Effects of Indoor Mold
).
conducted or sponsored by EPA, HHS, and HUD are provided in a
supplement to this report (see GAO-08-984SP
We surveyed officials at EPA, HHS, and HUD because of these agencies’
past and current participation in mold research. Specifically, we identified
these agencies based on federal reports to Congress summarizing efforts
to improve indoor air quality and interviews with federal officials involved
in this research, among other things. We took a number of steps to ensure
that our surveys would obtain reliable information from the appropriate
agencies and officials regarding federal research activities on the health
effects of exposure to indoor mold. For example, to ensure that we sent
surveys to all agency officials involved in indoor mold-related research
activities, we provided audit liaisons and agency respondents with a list of
the units and officials in their agencies that we had identified as being
relevant. We also asked audit liaisons to verify that we had not omitted any
relevant units within their agencies and confirm whether other agency
officials identified during our interviews as potentially involved in indoor
mold-related research activities were involved with relevant activities.
When an audit liaison identified a new agency respondent involved in
indoor mold-related research activities, the individual was provided with
copies of our surveys. (See app. IV for information on the units we
contacted at these agencies.) We pretested our survey questions by
sending them to two researchers from EPA and the National Institutes of
Health (NIH) and incorporating their feedback into the final surveys. To
increase the response rate, we followed up with agency officials to obtain
responses from all relevant parties. We also performed a series of
reliability tests on the data we received, including (1) examining agency
submissions to exclude any that were either duplicates or did not meet our
criteria and (2) checking for missing data or discrepancies. When we
identified discrepancies or inconsistencies in the data, we followed up
with relevant agency officials. In addition, we interviewed EPA, HHS, and
HUD officials to determine the extent to which they coordinate their
research projects and their priorities for mold-related research. To assess
the extent to which the Federal Interagency Committee on Indoor Air
Quality has been used to coordinate federal research activities related to
the health effects of exposure to indoor mold, we reviewed relevant
reports and the minutes of committee meetings dating from February 2005
to February 2008, and we interviewed EPA and other officials involved
with the committee.
To determine what guidance key federal agencies are providing to the
general public on the health risks of exposure to indoor mold, and on
minimizing mold growth and mitigating exposure to mold in their homes,
Health Effects of Indoor Mold
We selected guidance to the general public that
addresses health effects associated with indoor mold using a
nonprobability sample.
and the extent to which the guidance is consistent, we focused our review
on the five federal agencies that provide information to the general public
on health risks and minimizing and mitigating exposure to contaminants,
including mold. The guidance we reviewed includes fact sheets,
brochures, booklets, and Web pages.1 Specifically, we reviewed guidance
on the health effects of mold in a residential setting issued by the
Consumer Product Safety Commission, EPA, HUD, HHS, and the Federal
Emergency Management Agency (FEMA) that was identified primarily
through online searches of federal Web sites and interviews with relevant
program officials.23 We did not include technical documents targeted
to specialized audiences, such as medical professionals or emergency
response workers.4 Of the 78 guidance documents that met our initial
criteria, we selected 32 for detailed review on the basis of their content,
purpose, and the extent to which they specifically addressed indoor mold.
(In some cases, the documents broadly address indoor air contaminants
but only briefly mention mold.) Specifically, of the 34 mold-related
guidance documents FEMA issued to the general public responding to
specific disasters since 2004, we selected 8 for our review; we excluded
the other 26 because they contain essentially similar information. Further,
we included in our review the 8 guidance documents issued by the
Consumer Product Safety Commission and HUD that address health
effects associated with indoor mold; however, we excluded some guidance
documents issued by EPA and HHS primarily because they were similar to,
and thus duplicative of, other documents already included in our review.
We provided agency officials with an opportunity to review our list of
1We use the term guidance to describe non-binding communications agencies issue to the
public for educational purposes.
2We considered guidance to be issued by an agency if the agency is identified as its author
or the guidance displays the agency’s logo. Guidance documents can be sponsored by
multiple federal agencies, and some of the guidance we reviewed was also sponsored by
agencies other than those mentioned above, such as the Department of Agriculture.
3Nonprobability samples cannot be used to generalize or make inferences about a
population. In this instance, we cannot generalize the results of our review of federal
guidance to all federal guidance to the general public on the health effects of indoor mold
issued by the Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD.
4For example, we examined guidance from the Occupational Safety and Hazard
Administration of the Department of Labor, but excluded it from our analysis because the
mold-related information in this guidance was tailored to an occupational and professional
context only.
Health Effects of Indoor Mold
guidance documents and suggest additional documents for inclusion in
our review. We added relevant documents, as suggested. (See app. V for
the guidance documents included in our review.) Additionally, we
interviewed officials from the five agencies issuing the guidance to
determine their procedures for developing and issuing guidance
documents. The guidance documents we analyzed are publicly available
and can be accessed through the agencies’ Web sites.
We conducted this performance audit from January 2007 to September
2008 in accordance with generally accepted government auditing
standards. Those standards require that we plan and perform the audit to
obtain sufficient, appropriate evidence to provide a reasonable basis for
our findings and conclusions based on our audit objectives. We believe
that the evidence obtained provides a reasonable basis for our findings
and conclusions based on our audit objectives.
Health Effects of Indoor Mold
The following list of recent reviews of the health effects of mold includes
two Institute of Medicine reports and 20 other reviews.
Borchers A.T., Chang C., Keen C.L., and M.E. Gershwin. “Airborne
Environmental Injuries and Human Health.” Clinical Reviews in Allergy
and Immunology, vol. 31, no. 1 (2006): 1-102.
Bush R.K., Portnoy J.M., Saxon A., Terr A.I., and R.A. Wood. “The medical
effects of mold exposure.” The Journal of Allergy and Clinical
Immunology, vol. 117, no. 2 (2006): 326-33.
Douwes J. “(1—>3)-Beta-D-glucans and respiratory health: a review of the
scientific evidence.” Indoor Air, vol. 15, no. 3 (2005): 160-9.
Etzel R.A. “Indoor and outdoor air pollution: Tobacco smoke, moulds and
diseases in infants and children.” International Journal of Hygiene and
Environmental Health, vol. 210, no. 5 (2007): 611-6.
Fisk, W.J., Lei-Gomez Q., and M.J. Mendell. “Meta-analyses of the
associations of respiratory health effects with dampness and mold in
homes.” Indoor Air, vol. 17, no. 4 (2007): 284-96.
Gray, M. “Molds and Mycotoxins: Beyond Allergies and Asthma.”
Alternative Therapies in Health and Medicine, vol. 13, no. 2 (2007): S146-
52.
Green B.J., Tovey E.R., Sercombe J.K., Blachere F.M., Beezhold D.H., and
D. Schmechel. “Airborne fungal fragments and allergenicity.” Medical
Mycology, vol. 44, no. S1 (2006): S245-55.
Habiba A. “Acute idiopathic pulmonary haemorrhage in infancy: Case
report and review of the literature.” Journal of Paediatrics and Child
Health, vol. 41, no. 9-10 (2005): 532-3.
Hope, A.P., and R.A. Simon. “Excess dampness and mold growth in homes:
An evidence-based review of the aeroirritant effect and its potential
causes.” Allergy and Asthma Proceedings, vol. 28, no. 3 (2007): 262-70.
Institute of Medicine, Clearing the Air: Asthma and Indoor Air
Exposures. Washington, D.C.: National Academy Press, 2000.
Institute of Medicine, Damp Indoor Spaces and Health. Washington, D.C.:
The National Academies Press, 2004.
Appendix II: Recent Reviews of the Health
Effects of Mold
Appendix II: Recent Reviews of the Health
Effects of Mold
Health Effects of Indoor Mold
Jarvis B.B., and J.D. Miller. “Mycotoxins as harmful indoor air
contaminants.” Applied Microbiology and Biotechnology, vol. 66, no. 4
(2005): 367-72.
Khalili B., Montanaro M.T., and E.J. Bardana Jr. “Inhalational mold
toxicity: fact or fiction? a clinical review of 50 cases.” Annals of Allergy,
Asthma & Immunology, vol. 95, no. 3 (2005): 239-46.
Lai K.-M. “Hazard Identification, Dose-Response and Environmental
Characteristics of Stachybotryotoxins and Other Health-Related Products
from Stachybotrys.” Environmental Technology, vol. 27, no. 3 (2006): 329-
35.
Laumbach R.J., and H.M. Kipen. “Bioaerosols and sick building syndrome:
particles, inflammation, and allergy.” Current Opinion in Allergy and
Clinical Immunology, vol. 5, no. 2 (2005): 135-9.
Mazur L.J., and J. Kim; Committee on Environmental Health, American
Academy of Pediatrics. “Spectrum of Noninfectious Health Effects From
Molds.” Pediatrics, vol. 118, no. 6 (2006): e1909-26.
Nuesslein T.G., Teig N., and C.H. Rieger. “Pulmonary haemosiderosis in
infants and children.” Paediatric Respiratory Reviews, vol. 7, no. 1 (2006):
45-8.
Phipatanakul W. “Environmental Factors and Childhood Asthma.”
Pediatric Annals, vol. 35, no. 9 (2006): 646-56.
Seltzer J.M., and M.J. Fedoruk. “Health Effects of Mold in Children.”
Pediatric Clinics of North America, vol. 54, no. 2 (2007): 309-33, viii-ix.
Susarla S.C., and L.L. Fan. “Diffuse alveolar hemorrhage syndromes in
children.” Current Opinion in Pediatrics, vol. 19, no. 3 (2007): 314-20.
Portnoy J.M., Kwak K., Dowling P., VanOsdol T., and C. Barnes. “Health
effects of indoor fungi.” Annals of Allergy, Asthma & Immunology, vol.
94, no. 3 (2005): 313-20.
Richardson G., Eick S., and R. Jones. “How is the indoor environment
related to asthma?: literature review.” Journal of Advanced Nursing, vol.
52, no. 3 (2005): 328-39.
Health Effects of Indoor Mold
Notes: These data are for the 65 federal mold research activities ongoing as of October 1, 2007.
Federal officials reported which of the data gaps identified by the 2000 and 2004 Institute of Medicine
reports their research activities are addressing. Each activity can address multiple data gaps.
Appendix III: E
Research AIdentified b
Appendix III: EPA, HHS, and HUD Ongoing
Research Activities Addressing Data Gaps
Identified by the Institute of Medicine
Develop standardized metrics and protocols to assess the nature, severity, and ex-
tent of dampness and effectiveness of specific measures for dampness reduction.bBetter characterize the possible influence of the duration of moisture damage on
health.
Determine how to measure the effectiveness and health effects of mold remediation
efforts.
Develop information on the possible adverse health effects of dampness-related
emissions of mold spores from building materials and furnishings.
Collect and analyze data on the interactions among multiple indoor agents (such as
mold, pesticides, and volatile organic compounds) and environmental factors (such
as humidity, temperature, and ventilation).
Identify fungal allergens or patterns of cross-reactivity among fungal allergens.
Determine the association of dampness problems with asthma development and
symptoms by researching the causative agents (e.g., molds, dust mite allergens)
and documenting the relationship between dampness and allergen exposure.aImprove sampling and exposure assessment methods for mold and its components
(such as research that will help lead to standardization of protocols for sample col-
lection, transport, and analysis; or develop or improve methods of personal airborne
exposure measurement, DNA-based technology, or assays for bioaerosols, etc.)bIdentify environmental factors that either lead to the development of asthma or pre-
cipitate symptoms in subjects who already have asthma using good measures of
fungal exposure.aNumber of activities reportedSource: GAO analysis of EPA, HHS, and HUD survey data.
HUD research activitiesEPA research activitiesAssess the effects of housing interventions (such as prevention or remediation of
moisture problems, etc.) on dampness and adverse health effects, including the extent
to which interventions are associated with a decrease in the occurrence of adverse
health effects, and identify effective and efficient intervention strategies.
Better characterize the effectiveness of various means of protection used during
mold remediation activities.
Determine the effects of human exposure to Stachybotrys chartarum in indoor
environments.
Research the relationship between mold and dampness and acute pulmonary
hemorrhage or hemosiderosis in infants.
Determine, for mycotoxins, the dose required to cause adverse health effects in
humans via inhalation and dermal exposure; techniques for detecting and quantify-
ing mycotoxins in tissues; or the effects of long-term (chronic) exposures to
mycotoxins via inhalation.
Advance the understanding of specific bioaerosols in relation to asthma by studying the
epidemiology of building-related asthma in problem buildings where there are excess chestcomplaints among occupants in comparison to buildings where there are not complaints;
or provide exposure-response studies of many building environments and populations.
051015202530352118151313109554122223232HHS research activities
Health Effects of Indoor Mold
In fact, many of the activities are reported to address three or more gaps. Summaries of the 65
research activities conducted or sponsored by EPA, HHS, and HUD are provided in a supplement to
this report (GAO-08-984SP).
Agency officials reported that eight federal mold research activities currently being conducted do not
directly address any of the data gaps identified by the 2000 and 2004 Institute of Medicine reports.
Some of these studies were directed at medical treatments and others were focused on other
potential causes of asthma. For example, one study is evaluating whether chronic rhinosinusitis is
induced by an abnormal immune response to mold and therefore whether an anti-fungal agent will be
an effective treatment of the disease. Another study is developing and validating DNA-based methods
for identification and fingerprinting medically important fungi. Several of these research activities
focused on asthma. For example, two studies, one of children in El Paso and another of children in
Detroit, are primarily focused on the role of residential proximity to roadways in the development of
childhood asthma but also collected data on indoor exposures, including home dampness and the
presence of visible molds. Another study being conducted is designed to test the hypothesis that
asthma control in low income, urban adolescents and young adults can be improved with the addition
of exhaled nitric oxide as a marker for treatment guidance to conventional asthma management
guidelines; a secondary purpose of this study is to examine the role of allergy to molds in influencing
the effectiveness of the asthma management plan.
aAsthma data gaps identified by the 2000 and 2004 Institute of Medicine reports.
bMeasurement methods data gaps identified by the 2000 and 2004 Institute of Medicine reports.
Health Effects of Indoor Mold
We obtained information on federal research related to the health effects
of exposure to indoor mold from three key agencies—EPA, HHS, and
HUD. We obtained and analyzed information and interviewed program
managers and other officials responsible for research at these agencies.
Following are the offices, centers, and other program units we surveyed
regarding their mold-related research.1
Office of Air and Radiation
• Office of Radiation and Indoor Air
• Indoor Environments Division
• Radiation and Indoor Environments National Laboratory
• National Air and Radiation Environmental Laboratory
Office of Research and Development
• Office of the Assistant Administrator
• National Health and Environmental Effects Research Laboratory
• Experimental Toxicology Division
• Human Studies Division
• National Exposure Research Laboratory
• Microbiological and Chemical Exposure Assessment Research Division
• National Risk Management Research Laboratory
• Air Pollution Prevention and Control Division
• National Homeland Security Research Center
• National Center for Environmental Research
• National Center for Environmental Assessment
Office of Prevention, Pesticides, and Toxic Substances
• Office of Pesticide Programs
• Antimicrobials Division
• Field and External Affairs Division
• Special Review and Reregistration
• Office of Pollution Prevention and Toxics
• Environmental Assistance Division
Office of the Administrator
• Office of Children’s Health Protection and Environmental Education
• Child and Aging Health Protection Division
Appendix IV: FContacted ReResearch
Appendix IV: Federal Agency Program
Offices Contacted Regarding Their Mold-
Related Research
Environmental Protection
Agency
1We contacted at least one person in each program office. Officials in some of the program
offices listed in this appendix responded that they were not conducting or sponsoring any
mold research. In addition, some of the officials we contacted involved with indoor mold
research had left their agencies; their offices are not represented in this appendix.
Health Effects of Indoor Mold
Office of Solid Waste and Emergency Response
Office of Chief Science Officer
Coordinating Office for Terrorism Preparedness and Emergency
Response
Coordinating Center for Health Information and Service
• National Center for Health Marketing
Coordinating Center for Infectious Diseases
• National Center for Immunization and Respiratory Diseases
• Influenza Coordination Unit
Coordinating Center for Environmental Health and Injury
Prevention
• National Center for Environmental Health
• Division of Environmental Hazards and Health Effects
• Air Pollution and Respiratory Health Branch
• Division of Emergency and Environmental Health Services
• Lead Poisoning Prevention Branch
• Agency for Toxic Substances and Disease Registry
• Division of Health Assessment and Consultation
• Cooperative Agreement and Program Evaluation Branch
• Division of Health Studies
National Institute for Occupational Safety and Health
• Office of the Director
• Office of the Associate Director for Science
• Office of Extramural Coordination and Special Projects
• Health Effects Laboratory Division
• Pathology and Physiological Research Branch
• Allergy and Clinical Immunology Branch
• Division of Surveillance, Hazard Evaluations, and Field Studies
• Hazard Evaluations and Technical Assistance Branch
• Industrywide Studies Branch
• Division of Respiratory Disease Studies
• Field Studies Branch
• Laboratory Research Branch
Department of Health and
Human Services
Centers for Disease Control
and Prevention
Health Effects of Indoor Mold
National Center for Zoonotic, Vector-Borne, and Enteric Diseases
• Division of Foodborne, Bacterial and Mycotic Diseases
National Human Genome Research Institute
• Mycotic Diseases Branch
• Office of Population Genomics
National Institute of Allergy and Infectious Diseases
• Division of Clinical Research
• Division of Microbiology and Infectious Diseases
• Division of Allergy, Immunology, and Transplantation
• Office of Program Planning, Operations and Scientific Information
• Asthma, Allergy and Inflammation Branch
National Heart, Lung, and Blood Institute
• Division of Lung Diseases
• Division for the Application of Research Discoveries
National Institute of Environmental Health Sciences
• Office of the Director
• Division of Extramural Research and Training
• Division of Intramural Research
• National Toxicology Program
• Environmental Diseases and Medicine Program
• Clinical Research Program
• Office of Translational Research
Office of Public Health and Science
• Office of the Surgeon General
• Commissioned Corps of the U.S. Public Health Service
Program Support Center
• Chief Professional Officer
• Medical
• Environmental Health
• Health Services
• Scientist
• Federal Occupational Health
• Environmental Health Services
National Institutes of Health
Office of the Assistant
Secretary for Health
Office of the Assistant
Secretary for Administration
and Management
Health Effects of Indoor Mold
Office of the Assistant Secretary for Policy Development and
Research
• Office of Deputy Assistant Secretary for Research, Evaluation, and
Monitoring
• Affordable Housing Research and Technology Division
Office of Healthy Homes and Lead Hazard Control
• Policy and Standards Division
Office of Public and Indian Housing
• Office of Public Housing Investments
• Office of Capital Improvements
• Office of Native American Programs
• Real Estate Assessment Center
• Physical Inspection Quality Assurance Division
Office of Housing
• Office for Regulatory Affairs and Manufactured Housing
• Office of Manufactured Housing Programs
Department of Housing
and Urban Development
Health Effects of Indoor Mold
Consumer Product Safety Commission and the American Lung
Association, Biological Pollutants in Your Home (Bethesda, Md., 1990).
http://www.cpsc.gov/cpscpub/pubs/425.html (accessed May 8, 2008).
Consumer Product Safety Commission and the Environmental Protection
Agency, The Inside Story: A Guide to Indoor Air Quality (Washington,
D.C., 1995). http://www.epa.gov/iaq/pubs/insidest.html (accessed May 8,
2008).
Environmental Protection Agency, Addressing Indoor Environmental
Concerns During Remodeling (Washington, D.C., 2007).
http://www.epa.gov/iaq/homes/hip-concerns.html (accessed May 9, 2008).
Environmental Protection Agency, Age Healthier Breathe Easier
(Washington, D.C., 2004).
http://www.epa.gov/aging/resources/factsheets/ahbe_english_2004_0330.pdf (accessed May 9, 2008).
Environmental Protection Agency, A Brief Guide to Mold, Moisture, and
Your Home (Washington, D.C., 2002).
http://www.epa.gov/mold/moldguide.html (accessed May 9, 2008).
Environmental Protection Agency, Cleaning Up After a Flood: Addressing
Mold Problems (Washington, D.C., 2005).
http://www.epa.gov/katrina/outreach/mold.pdf (accessed May 9, 2008).
Environmental Protection Agency, Controlling Moisture (Washington,
D.C., 2007). http://www.epa.gov/iaq/homes/hip-moisture.html (accessed
May 9, 2008).
Environmental Protection Agency, Live, Learn, Play—Tune in to Your
Health and Environment (Washington, D.C., 2004).
http://yosemite.epa.gov/ochp/ochpweb.nsf/content/dirt.htm (accessed May
9, 2008).
Environmental Protection Agency, Flood Cleanup—Avoiding Indoor Air
Quality Problems (Fact Sheet) (Washington, D.C., 2003).
http://www.epa.gov/mold/pdfs/floods.pdf (accessed May 9, 2008).
Environmental Protection Agency, Flood Cleanup and the Air in your
Home (Washington, D.C., 2006).
http://www.epa.gov/mold/flood/index.html (accessed May 9, 2008).
Appendix V: Selected Publicly Available
Federal Guidance Related to Mold
Appendix V: Selected Publicly Available
Federal Guidance Related to Mold
Health Effects of Indoor Mold
Environmental Protection Agency, What are ten things I need to know
about mold? (Washington, D.C., 2008). http://iaq.custhelp.com/cgi-
bin/iaq.cfg/php/enduser/std_alp.php (accessed May 9, 2008).
Environmental Protection Agency, What You Can Do to Protect Children
from Environmental Risks (Washington, D.C., 2002).
http://yosemite.epa.gov/ochp/ochpweb.nsf/content/tips.htm (accessed May
9, 2008).
Environmental Protection Agency; Department of Agriculture,
Cooperative State Research, Education, and Extension Service;
Department of Housing and Urban Development; Montana State University
Extension Service; and Alabama Cooperative Extension System at Auburn
University, Healthy Indoor Air for America’s Homes (Bozeman, Mont.,
2007). http://www.montana.edu/wwwcxair/ (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Molds in the Environment (Atlanta, 2005).
http://www.cdc.gov/mold/faqs.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Facts About Mold And Dampness (Atlanta, 2005).
http://www.cdc.gov/mold/dampness_facts.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Mold Questions and Answers: Questions and Answers
on Stachybotrys chartarum and other molds (Atlanta, 2004).
http://www.cdc.gov/mold/stachy.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Protect Yourself from Mold (Atlanta, 2006).
http://www.bt.cdc.gov/disasters/mold/protect.asp (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Mold Prevention Strategies and Possible Health Effects
in the Aftermath of Hurricanes and Major Floods (Atlanta, 2006).
http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm (accessed
May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Population-Specific Recommendations for Protection
From Exposure to Mold in Buildings Flooded After Hurricanes Katrina
and Rita, by Specific Activity and Risk Factor (Atlanta, 2005).
Health Effects of Indoor Mold
http://www.bt.cdc.gov/disasters/mold/report/pdf/2005_moldtable5.pdf
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management
Agency, Dealing with Mold and Mildew in Your Flood Damaged Home
(Washington, D.C., 2005).
http://www.fema.gov/pdf/rebuild/recover/fema_mold_brochure_english.pdf (accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management
Agency, Got Mold? Clean, Disinfect and Dry (Wichita, Kans., 2007).
http://www.fema.gov/news/newsrelease.fema?id=37791 (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management
Agency, Mold Can Be A Danger When Evacuees Return Home (Baton
Rouge, La., 2005). http://www.fema.gov/news/newsrelease.fema?id=19302
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management
Agency, Mold—A Growing Threat (Andover, Mass., 2006).
http://www.fema.gov/news/newsrelease.fema?id=26898 (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management
Agency, Mold: A Health Hazard (Montgomery, Ala., 2005).
http://www.fema.gov/news/newsrelease.fema?id=20379 (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management
Agency, Mold: Potential Threat to Health and Homes (Austin, Tex., 2005).
http://www.fema.gov/news/newsrelease.fema?id=19767 (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management
Agency, Prompt Cleanup Of Mold And Mildew Is Essential (Newington,
N.H., 2006). http://www.fema.gov/news/newsrelease.fema?id=27186
(accessed July 1, 2008).
Department of Homeland Security, Federal Emergency Management
Agency, Water-Damaged Homes May Harbor Mold Problem (Washington,
D.C., 2007). http://www.fema.gov/news/newsrelease.fema?id=36536
(accessed May 9, 2008).
Health Effects of Indoor Mold
Department of Housing and Urban Development, About Mold and
Moisture (Washington, D.C., 2007).
http://www.hud.gov/offices/lead/healthyhomes/mold.cfm (accessed May 9,
2008).
Department of Housing and Urban Development, Healthy Homes Program
(Washington, D.C., 2003).
http://www.hud.gov/offices/lead/library/hhi/HH_Brochure_Revised.pdf
(accessed May 9, 2008).
Department of Housing and Urban Development, Mold and Moisture
Prevention: A Guide for Residents in Indian Country (Washington, D.C.,
2004).
http://www.hud.gov/offices/pih/ih/codetalk/docs/moldprevention.pdf
(accessed May 9, 2008).
Department of Housing and Urban Development, Mold (Washington, D.C.,
2005). http://www.hud.gov/offices/lead/library/hhi/Mold.pdf (accessed May
9, 2008).
Department of Housing and Urban Development; Department of
Agriculture, Cooperative State Research, Education, and Extension
Service; and University of Wisconsin Healthy Homes Partnership, Help
Yourself to a Healthy Home (Washington, D.C., 2002).
http://www.hud.gov/offices/lead/library/hhi/HYHH_Booklet.pdf (accessed
May 9, 2008).
Health Effects of Indoor Mold
John B. Stephenson, (202) 512-3841 or
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In addition to the contact named above, Christine Fishkin, Assistant
Director; Krista Breen Anderson; Nancy Crothers; Benjamin Howe;
Richard P. Johnson; Nico Sloss; and Ruth Solomon made key
contributions to this report. Linda Choy; Michael Derr; Alice Feldesman;
Terrance Horner; Armetha Liles; Luann Moy; and Anne Rhodes-Kline also
made important contributions.
Appendix VI:
A
Appendix VI: GAO Contact and Staff
Acknowledgments
GAO Contact
Staff
Acknowledgments
(360801)
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