CDC State of the Science on Molds and Human Health July 18, 2002

[Guest guest]

Statement for the Record

Before the Subcommittees on Oversight and

Investigations and Housing and Community

Opportunity

Committee on Financial Services

United States House of Representatives

State of the Science on Molds and

Human Health

Statement of

C. Redd, M.D.

Chief, Air Pollution and Respiratory Health Branch

National Center for Environmental Health

Centers for Disease Control and Prevention,

U.S. Department of Health and Human

Services

For Release on Delivery

Expected at 2:00 PM

on Thursday, July 18, 2002

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees

Good afternoon. I am Dr. Redd, the lead CDC scientist on air

pollution and respiratory

health at the Centers for Disease Control and Prevention (CDC).

Accompanying me today is Dr.

Sinks, Associate Director for Science of environmental issues

at CDC.

We are pleased to appear before you today on behalf of the CDC, an

agency whose mission is to

protect the health and safety of the American people. I want to

thank you for taking the time to

hear about the mold exposures in poorly maintained housing and other

indoor environments and

their effect on people's health. While there remain many unresolved

scientific questions, we do

know that exposure to high levels of molds causes some illnesses in

susceptible people. Because

molds can be harmful, it is important to maintain buildings, prevent

water damage and mold

growth, and clean up moldy materials.

Today I will briefly summarize for the committee

· CDC's perspective on the state of the science relating to mold and

health effects in people;

· CDC's efforts to evaluate health problems associated with molds,

· CDC's collaborations with other Federal agencies related to mold

and people's health;

· CDC's collaboration with the Institute of Medicine on mold and

health; and

· CDC's next steps regarding mold and health.

The State of the Science

Fungi are a kingdom of organisms that include mushrooms, mildews,

molds, and yeasts. It is

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???2

estimated that there are between 50,000 and 250,000 species of

fungi, and fewer than 200 have

been described as human pathogens that can cause infections. Molds

are ubiquitous in nature and

grow almost anywhere indoors and outdoors. More than 1,000 different

kinds of indoor molds

have been found in U.S. homes. Molds spread and reproduce by making

spores, which are very

small and lightweight, able to travel through air, capable of

resisting dry, adverse environmental

conditions, and hence capable of surviving a long time. Molds need

moisture and food to grow,

and their growth is stimulated by warm, damp, and humid conditions.

Molds can cause illnesses in situations other than humid indoor

environments. We have

documented that molds can cause infections in susceptible people,

particularly in hospital settings

where 9% of hospital-acquired (nosocomial) infections are caused by

fungi. Respiratory

infections due to inhalation of the fungus Aspergillus have been

documented mostly in

immunocompromised individuals. Molds also have been associated with

some cancers.

Two mold-produced toxins (aflatoxins and ochratoxin A) have been

classified by the National

Toxicology Program as human carcinogens (http://ntp-

server.niehs.nih.gov/). Chronic ingestion

of these toxins from eating contaminated foods has been associated

with liver and kidney tumors

in animals and people.

We also know that respiratory illnesses among workers may be

attributed to mold exposures. In

industrial and agricultural settings, various forms of

hypersensitivity pneumonitis (e.g., farmer's

lung, woodworker's lung, malt worker's lung), and other allergic

responses and infectious

respiratory diseases (e.g., aspergillosis) have been reported.

Farmer's lung is caused by

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???3

Thermoactinomycetes species or fungi found in moldy hay, straw, or

grain dust. Farmer's lung

has been extensively reported in many countries including the United

States, Canada, The

Scandinavian countries, France, and other European countries.

Reported prevalence of farmer's

lung ranges from 0.5% to 9.6% in farming populations.

Outbreaks of hypersensitivity pneumonitis also have been reported in

office buildings in relation to

exposures to mold-contaminated humidifiers and ventilation systems

(Arnow et al. 1987. Early

detection of hypersensitivity pneumonitis in office workers,

American Journal of Medicine

64:236-242 and Hodgson et al. 1987. An outbreak of recurrent acute

and chronic

hypersensitivity pneuomonitis in office workers. American Journal of

Epidemiology 125:631-638)).

We also know that molds can cause illness when people are exposed to

extensive mold growth

indoors. In its 1993 report " Indoor Allergens, " the Institute of

Medicine (IOM) concluded that

airborne fungal allergens were most often associated with allergic

diseases, such as allergic

rhinitis/conjunctivitis, allergic asthma, and hypersensitivity

pneumonitis. In its 2000 report

" Clearing the Air: Asthma and Indoor Air Exposures, " IOM concluded

that there is sufficient

evidence of an association between exposure to mold and

exacerbations of asthma. The IOM also

stated that there was inadequate evidence that molds caused people

to become asthmatic.

We do not know whether molds cause other adverse health effects,

such as pulmonary

hemorrhage, memory loss, or lethargy. We also do not know if the

occurrence of mold-related

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees

illnesses is increasing. Other than surveillance for hospital-

acquired infections, there is no system

to track the public's exposure to and the possible health effects of

mold.

Exposure to mold does not always result in a health problem.

However, routine measures should

be taken to prevent mold growth indoors because some people are, or

may become, allergic to it.

For people who are allergic to mold, common effects include hay-

fever-like allergic symptoms.

Certain individuals with chronic respiratory disease (chronic

obstructive pulmonary disease or

asthma) may experience difficulty breathing when exposed to mold.

Also, people with immune

suppression or underlying lung disease are more susceptible to

fungal infections.

CDC efforts to evaluate the health problems associated with molds

CDC has conducted several activities related to mold in wet indoor

environments and its effect on

people's health.

·In 1994, CDC conducted two epidemiologic investigations of reported

clusters of the acute onset

of bleeding from the lungs of very young children (pulmonary

hemorrhage or idiopathic

pulmonary hemosiderosis). In one investigation a possible

association was reported between

exposure to the mold Stachybotrys atra (S. atra) and disease. This

association was not reported

in the second investigation. In a further review of our first

investigation, CDC reviewers and an

external panel of experts determined that there was insufficient

evidence of any association

between exposure to S. atra or other toxic fungi and idiopathic

pulmonary hemosiderosis in

infants. CDC has plans to further evaluate the relationship between

pulmonary hemorrhage and

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???5

S. atra through state-based surveillance, further investigations of

identified disease clusters, and

focused research studies.

·In July 2001, following flooding in North Dakota, CDC investigated

Turtle Mountain

Reservation residents' concerns that mold contaminating their homes

might be contributing to an

increase in illness among tribal members. CDC assessed both the

physical and environmental

condition of the homes to identify any environmental hazards,

including the presence of mold, and

collected information on health conditions of the individuals living

in the homes. An interim

report identified several existing hazards unrelated to mold and

made recommendations to address

these hazards. The final report is expected in October 2002. In

addition to working with the

Indian Health Service and the Federal Emergency Management Agency

(FEMA) on this project,

CDC also worked with the U.S. Department of Housing and Urban

Development (HUD) to

identify procedures that might be implemented to assess conditions

of HUD homes that would

help to prevent mold.

· CDC responded to a request from the State of Texas and the City of

Houston in the summer of

2001, after the city experienced significant flooding, to assess the

conditions of the buildings and

provide advice on cleanup and repair of affected buildings. The

emphasis of this technical

assistance was cleanup and prevention of further mold growth and

prevention of unnecessary

exposure.

In 1999, CDC's occupational health experts began a 5-year initiative

on work-related asthma in

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???6

offices and schools, with an emphasis on moisture and mold

exposures. We have a targeted

research program regarding work-related asthma that includes

evaluations of workplaces,

intervention studies, and recommendations for reducing the risk of

respiratory disease, and

provision of information to management, employees and environmental

health and safety

professionals. The research aims are to be achieved utilizing

problem buildings identified through

the CDC's occupational Health Hazard Evaluation program. Specific

objectives include methods

development and testing, specifically with regard to state-of-the-

art techniques for assessing indoor

air quality-related exposures; quantification of objective medical

indices related to asthma and

other lung diseases; and planned case-control, cross-sectional, and

intervention studies directed

towards risk factor identification and assessment.

So far, the results include the following:

· there were significant relationships between reports of work-

related respiratory disease

and visual assessment of water and mold-damage in two studies;

· there were significant relationships between endotoxin and ultra-

fine particles in air and

work-related respiratory symptoms; and

· there were significant relationships between indicators of mold in

chair and floor dust and

work-related respiratory symptoms.

· CDC is planning an occupational and environmental research project

regarding bioaerosols in

schools to address children's and teacher's health issues.

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???7

· CDC is working to address indoor air quality issues, including

mold, in partnership with

stakeholders through the National Occupational Research Agenda

(NORA). NORA efforts have

resulted in development of the research priorities paper, " Improving

the Health of Workers in

Indoor Environments: Priority Research Needs for a National

Occupational Research Agenda, "

which identifies important areas for future research. The paper has

been accepted for publication

in the American Journal of Public Health (AJPH).

CDC's collaborations with other Federal agencies

CDC is working with federal, state, local, and tribal governments to

investigate and respond to

mold-related problems. I have already mentioned that we work with

HUD, FEMA, and the

Indian Health Service on mold issues. We have also assisted the U.S.

Environmental Protection

Agency (EPA) Indoor Environments Division in the development of a

guide for mold

remediation in schools and large buildings and in the development of

a brief guide to mold for

homeowners. CDC is participating in the development of a World

Health Organization guidance

document on exposures to biological agents in the indoor

environment; this document should be

finalized in the year 2003. CDC also has worked with the Council of

State and Territorial

Epidemiologists in the development of case definitions and

classifications for pulmonary

hemorrhage in infants.

CDC's collaboration with the Institute of Medicine

CDC is funding the IOM to evaluate the relationship between damp or

moldy indoor

environments and the manifestation of adverse health effects. Under

this project, the IOM will

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???8

conduct a comprehensive review of the scientific literature. The

review will focus on respiratory

and allergic symptoms and other non-allergic health effects. The IOM

will include

recommendations or suggest guidelines for public health

interventions and future research. The

IOM began the study in January 2002 and is expected to complete it

in the late summer or early

fall of 2003. To date, the IOM committee conducting the study has

held two meetings, the first

on March 26, 2002 and the second on June 17, 2002. A third meeting

is planned for Fall 2002.

The report will be disseminated to audiences such as relevant

federal agencies, state public health

and indoor air quality officials, academic institutions and

researchers, environmental firms, and the

building industry.

CDC's Next Steps

In response to concerns about mold and the gaps in scientific

knowledge, CDC is currently

developing an agenda for research, service, and education related to

molds. The results of this

effort will ultimately enable CDC to (1) make recommendations for

reducing mold contamination,

(2) identify environmental conditions that contribute to the

occurrence of disease following mold

exposure, and (3) assist state and local health departments in

improving their capacity to

investigate mold exposures. CDC is working to help strengthen state

and local capacity to

respond to requests regarding molds. Because there are no

quantitative standards, guidelines or

uniform recommendations for responding to mold in indoor

environments, each state or local

health department responds to public inquiries based solely on its

own experience. CDC is

working with the Council of State and Territorial Epidemiologists to:

· develop an inventory of state Indoor Air Quality programs;

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???9

· determine the extent to which these programs are coordinated to

respond to issues related

to indoor mold exposures;

· identify resources that states need in order to develop and

implement appropriate

responses; and

· develop a coordinated public health response strategy to mold

exposure.

CDC will continue to investigate and evaluate the health effects of

and quantify the risks

associated with, exposure to mold and poor indoor air. The

expectation is that such studies will

help to identify the environmental factors and antecedents

associated with mold contamination

and factors that determine poor health outcomes. For example, CDC is

developing a protocol for

investigating the possible health effects of exposure to mold in

indoor school environments. CDC

will use the knowledge, experience and skill gained from these

investigations and evaluations to

translate science-based findings into appropriate public health

interventions to reduce any health

risk found to be associated with mold exposure.

There are a number of barriers that need to be overcome in

investigating the possible effects of

molds on health. There are no accepted standards for mold sampling

in indoor environments or

for analyzing and interpreting the data in terms of human health.

Molds are ubiquitous in the

environment, and can be found almost anywhere samples are taken. It

is not known, however,

what quantity of mold is acceptable in indoor environments with

respect to health. Because of

difficulties related to sampling for mold, most studies have tended

to be based primarily on

baseline environmental data rather than human dose-response data.

For these reasons, and

because individuals have different sensitivities to molds, setting

standards and guidelines for

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???10

indoor mold exposure levels is difficult and may not be practical.

Despite the lack of standards,

CDC concurs with EPA's recommendation to remedy mold contamination

in indoor

environments to prevent negative health effects.

Summary

We do know that people who are exposed to molds may experience a

variety of illnesses. Fungi

account for 9% of nosocomial infections, that is, infections

originating or taking place in a

hospital. Ingestion of foods contaminated with certain toxins

produced by molds is associated

with development of human cancer. Many respiratory illnesses among

workers may be attributed

to mold exposures. Uncommon illnesses that collectively can be

called hypersensitivity

pneumonitis are caused by chronic exposures to high concentrations

of mold and are almost

exclusively limited to certain agricultural workers in particularly

moldy environments. Common

illnesses caused by molds include allergic conditions such as hay

fever and asthma.

Because molds can be harmful, CDC concurs with the general

recommendations of agencies such

as EPA and FEMA, which offer information on preventing and cleaning

up mold growth in

indoor environments. Linkages between indoor airborne exposures to

molds and other health

effects, such as bleeding from the lung, or memory loss, have not

yet been scientifically

substantiated. CDC and other organizations are taking steps to fill

the gaps in our knowledge

about linkages between exposure to mold and human health.

Thank you again for the opportunity to testify. I would be happy to

answer any questions that

you have.

State of the Science on Molds and Human Health July 18, 2002

House Financial Services Subcommittees ? ? ???11