Pediatric Environmental Health Health Effects of Indoor Mold Exposure

This educational module was produced by Rose Goldman, MD, MPH and Alan Woolf, MD, MPH for

The University of Texas Health Science Center at San Antonio

(UTHSCSA) Environmental Medicine Education Program and South Texas Environmental Education and Research Program (

STEER

-San Antonio/Laredo/Harlingen,Texas) Administrative support was provided by the Association of Occupational and Environmental Clinics through funding to UTHSCSA by the Agency for Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and Human Services.

Use of this program must include acknowledgement of the authors, UTHSCSA and the funding support.

For information about other educational modules contact the UTHSCSA STEER office, Mail Code 7796, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900,(210)567-7407.

Talk Objectives

The participant will…

 

Understand the pathogenesis of environment-related health problems Appreciate the taxonomy and regional variation of molds

 

Appreciate the relationship between molds and other microbial overgrowth in a damp space Know how to assess the patient with health complaints related to living in a damp space

  

Know how to assess the environment of a patient with damp space related complaints Be able to cite aspects of mold clean-up and prevention Know how to access resources for further information

Photos courtesy: EPA

Case: 14 month old with multiple respiratory illnesses? – Part 1



2 previous episodes bronchiolitis – 12 visits to local physician



2 episodes (1 hospitalization) for pneumonia



Father has chronic cough of 2- months duration and complains of headaches. No fever but some greenish nasal discharge.

 

Parents think that mold in their newly built home in this suburban community is the cause Here is the community…

Photo courtesy Alan Woolf, MD, MPH

Pathogenesis of environmental & toxic injury Contaminated Environment Absorption Distribution Metabolism Excretion Biological Uptake Biologically Effective Dose Target Organ Contact Biologic Change Repair Threshold Clinical Disease

Building-Related Medical Illness

Building-Related Medical Illness Specific Indoor Air Quality Problems Non-specific ‘sick building syndrome’

Allergic Non-Allergic

What are some of the Major Indoor Air Pollutants?

         Respirable particles Oxides of nitrogen Carbon monoxide Volatile Organic Compounds (VOC’s) Radon and radon daughters Asbestos fibers Toxic dusts (lead) Environmental tobacco smoke Biologic Agents (eg mold, endotoxin) and indoor allergens (mites)

Typical Damp Environment-Related Health Complaints

 Headache  Fatigue  Light headedness  Eye and nose irritation  Cough  Wheezing, exacerbation asthma  Skin itching and rashes

Risk Factors: Children



Which children are susceptible to inhaled exposures?



Why kids versus adults?



Where besides the home would you look for environmental contaminants affecting children?

Risk Factors: childhood illness from poor indoor air quality and dampness-related effects

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PHYSIOLOGY

»

Closer to ground-level toxins

»

Higher minute ventilation DEVELOPMENTAL

»

Pulmonary system

»

Immune system

»

Genetic SUSCEPTIBILITY

»

Prematurity?

»

Frequent wheezing, prior bronchiolitis

»

Chronic respiratory illness (e.g. cystic fibrosis) OTHER ENVIRONMENTS

»

Indoor air quality problems in school, preschool or daycare

Back to the case…

  This was a new home. There was no evidence for » » » » » » » Dusty environment Carbon monoxide (detectors in place) Oxides of nitrogen Radon Water intrusion Asbestos Lead Parents denied any exposure to » » Environmental tobacco smoke Use of solvents or other VOCs

Biological Agents Growing on Damp Indoor Spaces

Fungi Bacteria Dust mite Cockroach Picture courtesy: John Martyny, PhD - EPA

Respiratory Illnesses + Damp Environments

•

Asthma, wheezing, cough and phlegm associated with residing in damp or water damaged homes.

•

Irritant related nasal, eye, throat irritation

•

Dampness also associated with cockroach and mite infestation, bacterial growth (bacterial endotoxins), biofilms

Photo courtesy: EPA

Institute Of Medicine: Damp Spaces Sufficient Evidence - upper respiratory tract symptoms, cough, wheeze, asthma in sensitized person Limited evidence - dyspnea, lower tract illness in otherwise healthy person, asthma development

IOM Report: Damp Spaces

Inadequate or insufficient evidence:

•

Airflow obstruction, COPD

•

Acute idiopathic pulmonary hem. in infants

•

GI tract problems

•

Neuropsychiatric symptoms, fatigue

•

Reproductive effects

•

Rheumatologic and other immune diseases

Respirable Particles

    About 6000 liters of air exchange per day for an adult Smallest particles reach alveoli Some particles stimulate macrophage inflammatory response Water soluble chemicals cause proximal irritation, less deposition distally From chapter 16, Clinical Pulmonary Toxicology –author Lee S. Newman, in Sullivan JB and Krieger GR— Clinical Environmental Health and Toxic

Pathogenesis of injury from molds & damp spaces

Mold & Damp Spaces Allergy Infection Irritant

Mycotoxin

Case: 14 month old with multiple respiratory illnesses? – Part 2



2 previous episodes bronchiolitis – 12 visits to local MD



2 episodes (1 hospitalization) for pneumonia



Father has chronic cough of 2- months duration and complains of headaches



What is in your differential diagnosis?

Case: 14 month old with multiple respiratory illnesses? – Part 3



Pediatrician’s preliminary diagnosis = asthma

Pathogenesis of injury from molds & damp spaces

Mold & Damp Spaces Allergy

Rhinitis ABPA Asthma rashes Hypersensitivity Pneumonia

Allergic and Hypersensitivity Reactions

About 10% of the population has allergic antibodies to fungal antigens, and 5% have clinical illness Outdoor molds more abundant and important in airway allergic disease Allergic rhinitis (“hay fever”) or asthma “Atopic” individuals: mast cell degranulation, IgE antibodies (immediate hypersensitivity) Indoor common molds:

Penicillium

,

Aspergillus

Outdoor:

Cladosporium

,

Alternaria

(but can also come indoors)

Uncommon Allergic and Hypersensitivity syndromes

Allergic bronchopulmonary aspergillosis (ABPA)-growth of

aspergillus

in allergic persons, or those with cystic fibrosis, with airway damage from previous illnesses Allergic bronchopulmonary mycosis Allergic Fungal Sinusitis (AFS)-

Aspergillus, Curvularia

Specific criteria for ABPA and AFS Exposure to ubiquitous organisms-no link to specific exposures at home or school

Hypersensitivity Pneumonitis

•Rare, exposures (usually occupational) to

very high

concentrations of fungal (or other) proteins •High levels of IgG proteins-detected in precipitin tests or gel diffusion (BUT can have +IgG ab, no disease) •Cell-mediated and humoral immune reactivity-delayed intense local reactions •Examples in humidifier and HVACs-thermophilic Actinomyces (filamentous bacteria)

Allergy Assessment

        

Blood count, white cell count, % eosinophils Nasal eosinophils Immune competency: Ig levels, IgE Sweat test Chest x-ray RAST testing (Sensitivity testing) (Pulmonary function tests) (Provocative testing) () reserved for older patients

The family’s discovery…

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Attic had no fan and very small soffets

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It was a rainy, wet spring following the home’s construction

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The builder had used improperly cured ‘green’ plywood

Black mold in a newly constructed home

Photo courtesy Alan Woolf, MD, MPH

Photo courtesy Alan Woolf, MD, MPH

molds are everywhere…

Photos courtesy: Rose Goldman, MD, MPH

Boston Globe – 06/14/03

Flooding from Katrina

Types of indoor molds commonly associated with adverse health effects

    

Alternaria – most common allergen Aspergillus (A. fumigatus, flavus, niger) species, including 16 known human pathogens; filamentous, some strains mycotoxin-producing – 175 Penicillium – 200 species, indoors, allergenic (hypersensitivity pneumonia, allergic alveolitis, keratitis, otomycosis, penicilliosis) Stachybotrys atra – thrives on cellulose (e.g. sheetrock, wallpaper, paper-backed gypsum, ceiling tiles, insulation), causes dermatitis, rhinitis, nose bleeds, cold symptoms, malaise Cladisporium – ubiquitous, breaks down cellulose, pectin, lignin, buoyant spores

Photos courtesy John Martyny, PhD - EPA

What about the father’s complaints of cough and headache?

What other information do you need to know about his illness?

Differential diagnosis considerations of cough & headache in an adult



Pneumonia



Chronic Bronchitis



Cough-Equivalent Asthma



Gastroesophageal reflux



Migraine



Tension Headache



Dental abscess



Sinusitis

Pathogenesis of injury from molds & damp spaces

Mold & Damp Spaces Allergy Infection Immuno Compromised Irritant

Mycotoxin

Case Outcomes

     Parents relocated to grandparents’ home in the next town No further health complaints: child or father Family successfully sued builder for remediation This outcome does not complaints

prove

that mold caused the health For example, airborne and dust-laden

endotoxin

from bacteria,

volatile organic compounds

associated with microbial overgrowth,

dust mite

airborne

particulates

or

cockroach

antigens, or might also have played causative roles

Pathogenesis of injury from molds & damp spaces

Mold & Damp Spaces Irritant: direct or VOC mediated

Eye, nose, throat symptoms Cough, wheeze

Pathogenesis of injury from molds & damp spaces

Mold & Damp Spaces

Mycotoxin Infantile pulmonary Hemorrhage?

Pneumonia

Examples of Mycotoxins

Photo courtesy: Terry Brennan - EPA          

Aflatoxin Cyclochloritine Ethanol Griseofulvin Ipomeamarone Luteoskyrin Ochratoxin Sporidesmin Sterigmatocystin Tetracycline

Poisoning related to mycotoxins



Toxigenic species do not always produce toxins



Mycotoxins: usually large, non-volatile molecules that do not ‘off-gas’ or pass through walls

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Ingestion of moldy foods (e.g. aflatoxin in grains produces hepatitis & hepatocarcinoma)

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Stachybotrys species produce trichothecenes

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Stachybotrys-associated infantile pulmonary hemorrhage

STACHYBOTRYS

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Greenish black, saprophytic, grows well on cellulose Produces spores in a slimy, mucilaginous mass Some species produce trichothecenes Controversy over 10 cases infantile pulmonary hemorrhage in Cleveland, Ohio

Photo courtesy EPA

Stachybotrys chartarum

Kuhn DM, Ghannoum MA. Clin Microbiol Rev 2003; 16:144-72

•

Is there illness found with building associated mycotoxins produced by Stachybotrys , or “toxic mold”?

•

Acute pulmonary hemorrhage in infants in room with Stachybotrys-?related

•

For toxicity: need high exposure - What is a toxic dose? Could it occur in a typical indoor environments

•

current human studies “uniformly suffer from significant methodological flaws, making their findings inconclusive…have not found supportive evidence for serious illness due to Stachybotrys exposure...”

Pathogenesis of infection from molds

Mold & Damp Spaces Infection

Skin & nail infections

Immuno Compromised

other systemic infection Sinusitis ABPA pneumonia

Fungal Pathogens

Fungal Pathogens - regional, often do not grow indoors •

Candida -

ubiquitous •

Cryptococcus -

associated with bird droppings •

Histoplasma -

(bats) Ohio valley •

Coccidioides -

Southwestern U.S.

Visual Assessment - Environment

•

Interior materials : wet carpet, insulation

•

Building materials : wet wood, wallboard, ceiling tiles

•

Furnishings : damp fleecy furnishings

•

Heating, Ventilation, Air Conditioning (HVAC) : condensate pans, moist dirty

Photo courtesy Terry Brennan - EPA

ductwork

•

Pipes, Drainage : clogged drains, wet traps, leaking water pipes, wet pipe wrappings

•

Ventilation : blocked soffets & vents, no fans

Photo courtesy John Martyny, PhD - EPA

Assessment of possible mold-related illness

•

Biological assessment

: characterize signs and symptoms – confirmatory testing when indicated •

Environment

: visual inspection air samples (spore count, CFU/m3) Photos courtesy EPA website

Indoor airborne fungi levels

•

Indoor air levels are a reflection of outdoor levels (estimated at 40% 80% of outdoor levels) with similar

•

rank order species of fungi. Concentrations of fungi in samples not exposed directly to indoor air

•

may not indicate inhalation risk Estimated that 70% of homes have some mold growing behind walls.

Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309 Photo courtesy EPA

Examples of seasonal total mold counts in the U.S.

Location

St. Louis Las Vegas

March–June: spores/m

395–24,500 8–673

3 Sept–Dec: spores/m

5266–68,855 15–186 Albany, NY 9–1534 1075–18,005 Santa Barbara,CA 544–33,090 767–555,833

Data from

the National Allergy Bureau, American Academy of Allergy, Asthma and Immunology. Pollen and mold counts. Available at: http://www.aaaai.org

3

Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309 Photo: courtesy Rose Goldman, M.D.

Limitations of Testing

     Airborne spores are usually 4 100 microns diameter Spore counts do not necessarily predict symptoms Not all spores are equally pathologic Spore counts may fluctuate daily, seasonally This is not an exact science!

Photos courtesy John Martyny, PhD – EPA website

Management & Prevention

Photo by: Mike Ahlers, CNN Photo: FEMA, Naumann

What do you see in these pictures?

What is possibly the composition of the slime?

What good & bad practices do you see in the clean-up?

Hazard Reduction

  

Environment : Prevent water intrusion, all reused materials dried and visibly mold-free Clean-Up disposal : Proper PPE, Mold disinfectant (hypochlorites) or – EPA recommends hiring a professional for mold growths > 10 square feet in size Monitoring Post-occupancy : De-humidification < 60% relative humidity

Above photo courtesy Chin Yang

N-95 respirator

3 photos courtesy Terry Brennan & EPA website

Summary

    

Mold-related exposures : over-diagnosed, costly, preventable Damp spaces : cause poor health (mold only one of many concerns) Children’s differences : size, physiology, development, behaviors Mechanisms of mold injury :

» »

Irritant Allergy

» »

Infectious Toxic Common clinical issues :

»

Mold-related illness:

–

diagnosis & medical management

» »

Safe environmental clean-up Prevention

Resources: Mold-Related Illness  Clinical Resources: Occupational & Environmental Clinics; Pediatric Environmental Health Subspecialty Units; AOEC  Local & State Health Departments  ATSDR & Regional EPA