MOLD INVESTIGATION MEDICAL GUIDANCE- Revised 03

[Guest guest]

This one sentence caught my eye. " The Centers for Disease Control

and Prevention (CDC) currently state that determining what type of

mold exists is unnecessary, and that all molds should be treated the

same with respect to potential health risks and removal. "

http://www-nehc.med.navy.mil/Downloads/IH/IHFOM/IHFOM_CH13-4.pdf

CHAPTER 13, SECTION 4

MOLD INVESTIGATION MEDICAL GUIDANCE

INTRODUCTION

Molds may affect human health by three mechanisms: infection (by

exposure of a susceptible individual to mold spores; generally but

not always a person who is immunocompromised), hypersensitivity

(allergy to mold spores, components, or toxins, including asthma and

hypersensitivity pneumonitis), or direct irritation (by mycotoxins,

the toxins produced by mold).

In general, results from a large indoor air study1 found that:

& #56256; & #56510; culturable airborne fungal concentrations in indoor air are

lower

than those in outdoor air;

& #56256; & #56510; fungal concentrations are highest in the fall and summer and

lowest in the winter and spring;

& #56256; & #56510; geographically in the continental U.S., fungal concentrations

are

highest in the southwest, far west, and southeast; and

& #56256; & #56510; the most common culturable airborne fungi, both indoors and

outdoors and in all seasons and regions, were Cladosporium,

Penicillium, nonsporulating fungi, and Aspergillus.

Considerable interest and controversy have been generated recently

about searching for and identifying specific molds in buildings. The

Centers for Disease Control and Prevention (CDC) currently state

that determining what type of mold exists is unnecessary, and that

all molds should be treated the same with respect to potential

health risks and removal.2

Mold may proliferate almost anywhere that has too much moisture.

Even if renovation is done properly, recurrence of moist conditions

may cause mold regrowth. In one study, uninstalled wallboard

available from local distributors was found to contain a baseline

bioburden, including Stachybotrys chartarum. The authors noted that

sanitation and preservation treatment of the wallboard can markedly

delay regrowth of certain fungi, particularly of S. chartarum.3

Mold has been considered as a causative agent of building related

illness (BRI). Building related illnesses are caused by known

pathogens, have specific symptoms, and may be serious. Specific

diseases include those caused by Legionella species (Pontiac Fever,

Legionnaire's Disease) and humidifier fever. Other airborne

infectious diseases may have increased transmission when there is

inadequate ventilation4 (e.g., Tuberculosis 5, 6 Varicella,7 and Q

fever8). Other symptoms from indoor air contamination of offices

where workers shared ventilation contaminated with algal toxins

(Pfiesteria piscicida, a dinoflagellate) are suspected to have

occurred.9

Revised 7/18/03

Prudent health practice dictates limiting exposure of

immunocompromised persons to excessive levels of mold spores and

limiting exposure of sensitized (allergic) individuals to airborne

or surface contamination of the specific mold to which the

individual is sensitized.

THE PHYSICIAN'S ROLE IN THE INVESTIGATION AND RESOLUTION OF MOLD-

RELATED PROBLEMS

The medical member of the indoor environmental quality (IEQ)

investigative team can contribute valuable expertise in advising

what organisms the industrial hygienist (IH) should sample for. If

there is reason to suspect a particular species of mold - because of

worker concern, fungal infection, or identification by a worker's

health care provider (HCP) of allergy to a specific mold - IH can be

asked to direct sampling to recover and appropriately identify that

organism. Requesting IH to " sample for molds " because of non-

specific symptoms in workers will generally not be helpful, since

simply the presence of molds may be insignificant with respect to

human health.

Communication between medical and other team members is important

when trying to determine if there is an exposure pathway. For

example, discovery of mold on surfaces may be incidental in a

situation where airborne contamination is the problem (e.g.,

Legionella).

RETURNING WORKERS TO A BUILDING UNDER INVESTIGATION

In general, it is preferable not to keep workers out of the work

area, nor to advise workers to avoid returning to a building unless:

(1) a diagnosis of a building-related illness has been established,

or (2) a building-related diagnosis is suspected based on symptoms,

disease patterns, and findings consistent with a building-related

illness.

If a worker is confirmed to have building-related mold or other

allergy, the worker should not be allowed back into the building

until remediation has been completed and post-remediation sampling

documents confirm reduced levels of mold. After remediation, re-

exposure should be done with caution. It may be appropriate to have

medical care immediately available in the case of serious allergic

reactions. If remediation has been adequate, there is reason to

expect the worker may successfully return to a building with few or

no mold-related symptoms.48

The etiology of a worker's condition may be unknown, but the

worker's condition is serious enough that further exposure to any

potential offending agent represents an unacceptable health risk. In

such cases, the prudent HCP may recommend against further exposure

to a building until the medical workup is complete. However, the HCP

should complete the workup thoroughly and accurately, being careful

to avoid labeling the building a " health hazard " or stating that

mold in the building is the etiology until after the facts have

established such a link. Incorrectly identifying building mold as a

source of health hazards can cause undue anxiety and loss of income

among workers, decreased productivity, increased operating costs,

and decreased readiness. Once a causal relationship has been

established, however, relocation of affected workers to a different

building may be appropriate.

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A case report of office-related Alternaria allergy supports the

following as " considerations " for concluding an association exists

between IEQ-related mold exposure and illness in an occupational

setting: symptoms and signs consistent with a medical diagnosis;

either in vitro or in vivo evidence of exposure; environmental

evidence of plausible biological exposure; and substantial

improvement or resolution of the illness after appropriate building

remediation.49

REMEDIATION

Successful remediation can result in a building that can be

reoccupied without recurrent related illness, even in a subtropical

climate.48

If sampling reveals pathogens suspected because of the symptoms or

signs exhibited by building occupants, remediation effectiveness

should be confirmed by clearance sampling before building

reoccupation. Building processes (for example, heating, ventilation,

and air-conditioning (HVAC) and humidification systems or decorative

fountains) that may be similar in other buildings may warrant

preventive attention as a public health measure. Building engineers,

inspectors, or public health officials may be appropriate points of

contact in such situations.

INFECTIONS DUE TO MOLD

Molds are usually opportunistic pathogens, causing clinically

significant infections only in cases of overwhelming exposure or in

individuals who are immune compromised (i.e., debilitated by

extremes of age, underlying infection, poor sanitation, inadequate

nutrition, wounds); immune suppressed (chemotherapy, severe stress,

pregnancy); or immune deficient (human immunodeficiency virus). Mold

infection diagnoses will be made by appropriate microbial

identification studies or clinical courses (which are beyond the

scope of this document).

ALLERGIES/ ALLERGENS

Respiratory or skin (allergic contact dermatitis) allergy symptoms

are the most likely symptoms encountered from building-related mold

allergy. Sensitivity to mold allergens is an important risk factor

for adenoid hypertrophy in children with allergic rhinitis.10 Adult-

onset asthma is associated with self-reported mold exposures in the

home.11 Other organ system involvement, such as gastrointestinal

hypersensitivity-related complaints, may be a clue that the

offending exposure may not be indoor environment related, but rather

related to an ingested allergen.

Allergens are common in most environments. Certain classes of

allergens are especially pertinent to an indoor environmental

quality investigation. Again, the history given by those affected

can be the most helpful information in determining the source of the

problem. In addition to potential for infectious disease, molds can

cause allergic problems. Buildings that have been water damaged for

several days or more - whether from flood, leaking roofs or walls,

broken plumbing, improperly installed or adjusted humidifiers, or

condensation on cold surfaces - may become culture media for any of

a number of molds and fungi.

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Specific IEQ-associated illnesses with an allergic (sensitization)

basis include asthma, hypersensitivity pneumonitis, rhinitis or

sinusitis, bronchitis or tracheitis (usually associated with

sinusitis), and humidifier fever (HF). HF is thought to be allergic,

as patients have shown sensitivity and symptoms with exposure to

specific antigens in humidifiers.15 HF has been associated with

contamination of humidifiers by biologicals including amoeba, 16

fungi,17, 18 Bacillus subtilis,19 endotoxins,20 flavobacterium,20

and Pseudomonas species.21 It is also possible that not all

etiologies of IEQ-related allergic complaints are biologicals, as

one report noted HVAC " dust and mud. " 22

Spirometry may help document involvement of the lower respiratory

tract. A peak flow meter may be the simplest way to document

expiratory impairment or exacerbation of asthma with building

exposure.12 A significant association was found between basophil

histamine release showing serum IgE specific to one or more indoor

molds, and building-related symptoms in individuals working in damp

and moldy buildings.13 Skin testing (skin prick test) may be more

sensitive than blood testing (radioallergosorbent test, commonly

called RAST) in detecting sensitization to molds.14 However,

determining a specific mold to which someone is allergic in a given

situation may be difficult, as sensitized individuals often react to

more than one species.14

IRRITATION

Stachybotrys mycotoxins are biologically active,23 and it is thought

that they act as irritants. Respiratory irritation has been

documented to occur in rodents exposed to Stachybotrys.24 Special

conditions may be necessary for mycotoxins produced by surface

Stachybotrys in a building to reach sufficient concentrations to

cause such effects, according to the results of one experimental

study.25 The controversy is noted previously as to whether

documentation is sufficient that direct irritation from mycotoxins,

rather than a hypersensitivity-related response to molds or

mycotoxins, has occurred in humans exposed to mold in indoor air.

The primary indicator that symptoms among workers may be caused by

building-related mold is that there is a temporal relationship of

the symptoms to building exposure. Mold allergy may involve both IgG

and IgE immunoglobulins.26 Thus, an allergic reaction may occur

immediately on entering a building, after several hours of exposure,

or even 2 to 8 hours after leaving the building. A clear worker

history of a temporal association of allergy symptoms with building

exposure should alert the health care provider to the possibility of

building-related allergy.

It is unknown how much exposure time is required before sensitivity

to mold develops. As many molds are commonly found outside of the

workplace, it is expected that some individuals have been sensitized

prior to any occupational exposure. Further, since development of

allergy to some substances may take over 30 years of exposure,27 it

is probable that in certain individuals, sensitization develops only

after many years.

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ASPERGILLUS

Aspergillus species molds are commonly found. Inhalation of

Aspergillus conidia or mycelium fragments may result in airway

colonization, which may subsequently cause infections in susceptible

hosts.28 A significant relationship was found between the incidence

of invasive nosocomial aspergillosis and the degree of fungal

contamination of air and surfaces in patient rooms in a bone marrow

transplantation unit and two hematology wards.29 As an antigen,

hypersensitivity to A. fumigatus may cause Aspergillus asthma and

allergic bronchopulmonary aspergillosis (ABPA).28 Specific IgE and

IgG may be detected in ABPA. X-ray studies are characterized by

fleeting pulmonary infiltrates that are often confused with

pulmonary tuberculosis on chest x-ray, and by central bronchiectasis

on chest CT (computerized tomography). Early diagnosis and therapy

may alter the course of the disease and prevent the development of

end-stage lung fibrosis.26

Aspergillus candidus, common in grain dust, has been suggested to be

an etiologic factor in organic dust toxic syndrome30 and to pose an

important occupational hazard for grain handling workers through its

immunomodulating properties.31

Aspergillus versicolor has been found in an investigation of

building-related complaints, but no association was seen between IgE

or IgG antibodies and the presence of disease.32

STACHYBOTRYS

Stachybotrys chartarum (also called Stachybotrys atra) has been

known as an animal pathogen, and has recently attracted attention as

possibly having a role in human IEQ-related disease.23 It is a

toxigenic fungus frequently found in water-damaged buildings.33 In

one study, S. chartarum was identified in the indoor air in 6% of

the buildings studied and in the outdoor air of 1% of the buildings

studied.1 S. chartarum has been found to produce volatile organic

compounds that are quite different from those produced by

Aspergillus.33

S. chartarum produces trichothecene mycotoxins, which are

biologically active and can produce a variety of physiological and

pathologic changes in humans and animals, including modulation of

inflammation and altered alveolar surfactant phospholipid

concentrations.23 Sensitivity to Stachybotrys has been found to

involve both immunoglobulin IgE and IgG against antigenic proteins

of S. chartarum.34 Effects of S. chartarum may be related to direct

irritant as well as immunologic properties. Inhalation of S.

chartarum extract aerosols was observed to provoke sensory

irritation in the airways of both naive and immunized mice.24

Alveolar type II cells are sensitive to exposure to S. chartarum

spores and mycotoxin (isosatratoxin-F, a trichothecene).35

S. chartarum has been associated with nasal bleeding in adults.

Stachylysin, a mycotoxin, may be one chemical responsible for the

hemorrhagic effects.36 Stachyrase A, a chymotrypsin-like proteinase

from S. chartarum, has been isolated from a child with pulmonary

hemorrhage.37 A possible association between S. chartarum and

pulmonary hemorrhage/hemosiderosis in infants has been reported, but

further review of evidence by the CDC and other experts concluded

that the association was unproven.38

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Articles are not consistent as to the significance of Stachybotrys

in relation to human health. Two reviews have found inadequate

evidence to clearly establish the place of Stachybotrys in human

disease.39, 40

OTHER MOLDS AND MOLD-RELATED ORGANISMS

Thermophilic Actinomyces and Aspergillus fumigatus have been

suggested as possibly having a causative antigenic role in

stipatosis, a hypersensitivity pneumonitis found in Mediterranean-

area stucco workers exposed to those organisms in esparto grass

(Stipa tenacissima).41 Note that although the name Actinomyces

suggests a fungus, actinomycosis is a bacterial infection.

Cladosporium cladosporioides was found to be the etiologic agent of

hypersensitivity pneumonitis associated with a hot tub.42 Skin

sensitization to C. cladosporioides was the most commonly found mold

skin sensitization in a small population in Toronto, Canada.43

Fusarium species infections in a hospital led to an investigation

that identified the water distribution system of the hospital as the

reservoir of Fusarium. Aerosolization of Fusarium species was

documented after running the showers.44

IgG to Sporobolomyces salmonicolor was the most commonly detected

anti-mold immunoglobulin associated with exposure in a Finnish

military hospital building with severe, repeated, and enduring water

and mold damage. Rhinitis, asthma, and alveolitis were noted among

personnel reacting positively to S. salmonicolor provocation tests.45

Streptomyces albus was found to be responsible for a biopsy-proven

case of hypersensitivity pneumonitis.46

An increased risk of developing asthma in adulthood has been found

to be significantly related to IgG antibodies to Trichoderma

citrinoviride (but not to other molds).47

For more information on IEQ medical guidance, contact Occupational

Medicine at (757) 953-0769 or occmed@.... Page 6 of 11

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http://www.ncbi.nlm.nih.gov/entrez/query.fcgi

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