Re: The Relationship between Mold Exposure and Allergic Respo...

[Guest guest]

Mayleen,

You need to read that paper in detail. The gist is that they only

included those who had health insurance in the study and only looked for IgE

response as an indicator of illness. That paper is full of double speak. The

title does not match the actual findings of the paper with regard to

establishing if Katrina caused long term health effects in the general

population

of New Orleans.

" The purpose of this study was to examine the relation between reported

exposure to mold/dampness and mold-specific a-l-l-e-r-g-i-c

s-e-n-s-i-t-i-z-a-t-i-o-n among residents "

THEY CANNOT FORM THIS CONCLUSION BASED ON THE DATA AND SUBJECTS THEY USED:

" Conclusions. These results along with results of earlier research

indicate no excess risk of adverse respiratory effects for residents living in

New

Orleans after the devastation of Hurricane Katrina. "

The Relationship between Mold Exposure and Allergic Response in

Post-Katrina New Orleans

_Felicia A. Rabito_ (http://www.hindawi.com/90437275.html) ,1 _Sara _

(http://www.hindawi.com/31574071.html) ,1 _W. _

(http://www.hindawi.com/46321910.html) ,2 _C. Lillian Yau_

(http://www.hindawi.com/30459517.html) ,3 and _Estelle Levetin_

(http://www.hindawi.com/35618261.html)

41Department of Epidemiology, Tulane University School of Public Health and

Tropical Medicine, 1440 Canal Street SL-18, New Orleans, LA 70112, USA

2Allergy and Immunology, Ochsner Health System, 1514 Jefferson Highway,

Jefferson, LA 70121, USA

3Department of Biostatistics, Tulane University School of Public Health

and Tropical Medicine, 1440 Canal Street, New Orleans, LA 70112, USA

4Faculty of Biological Science, The University of Tulsa, 600 S. College,

Tulsa, OK 74104, USA

Received 12 November 2009; Revised 30 March 2010; Accepted 3 April 2010

Academic Editor: Ting Fan Leung

Copyright © 2010 Felicia A. Rabito et al. This is an open access article

distributed under the Creative Commons Attribution License, which permits

unrestricted use, distribution, and reproduction in any medium, provided the

original work is properly cited.

Abstract

Objectives. The study's objective was to examine the relation between

mold/dampness exposure and mold sensitization among residents of Greater New

Orleans following Hurricane Katrina. Methods.

*****Patients were recruited from the Allergy Clinic of a major medical

facility. Any patient receiving a skin prick test for one of 24 molds between

December 1, 2005 and December 31, 2008 was eligible for the study.******

Exposure was assessed using standardized questionnaires.

**********Positive mold reactivity was defined as a wheal diameter >3 mm to

any mold

genera.*********** Results. Approximately 57% of participants tested positive

to

any indoor allergen, 10% to any mold. Over half of respondents had

significant home damage, 34% reported dampness/mold in their home, half engaged

in

renovation, and one-third lived in a home undergoing renovation. Despite

extensive exposure, and multiple measures of exposure, we found no

relationship between mold/dampness exposure and sensitivity to mold allergens.

THEY CANNOT FORM THIS CONCLUSION BASED ON THE DATA AND SUBJECTS THEY USED:

Conclusions. These results along with results of earlier research indicate

no excess risk of adverse respiratory effects for residents living in New

Orleans after the devastation of Hurricane Katrina.

1. Introduction

Residing in damp or water damaged homes is closely associated with

observations of mold, mildew, and other microbial growth and has been associated

with respiratory illnesses [_1_

(http://www.hindawi.com/journals/ja/2010/510380.html#B1) –_4_

(http://www.hindawi.com/journals/ja/2010/510380.html#B4) ].

The Institute of Medicine concluded that there is a causal link between

indoor dampness and upper respiratory tract symptoms, cough, wheeze, and

asthma symptoms in sensitized people, and hypersensitivity pneumonitis in

susceptible people [_5_ (http://www.hindawi.com/journals/ja/2010/510380.html#B5)

]. An estimated 21% of current asthma is attributable to dampness/mold in

homes [_6_ (http://www.hindawi.com/journals/ja/2010/510380.html#B6) ]. Many

molds produce IgE-inducing allergens and studies have shown higher

prevalence of mold sensitization among people living in damp homes and homes

with

elevated concentrations of molds [_7_

(http://www.hindawi.com/journals/ja/2010/510380.html#B7) –_9_

(http://www.hindawi.com/journals/ja/2010/510380.html#B9) ].

Molds and other fungi may adversely affect human health through allergy,

infection, and toxicity. Approximately 40% of the population is atopic and

express high levels of allergic antibodies to inhalant allergens [_10_

(http://www.hindawi.com/journals/ja/2010/510380.html#B10) ]. In atopic

individuals, inhalation of allergens can trigger an immune response

characterized by

eosinophilic inflammation, constriction of the airways, and increased levels

of IgE antibodies [_11_

(http://www.hindawi.com/journals/ja/2010/510380.html#B11) , _12_

(http://www.hindawi.com/journals/ja/2010/510380.html#B12) ].

An estimated 50–75% of asthma cases are attributed to atopy and 10% of the

population has allergic antibodies to fungal antigens [_10_

(http://www.hindawi.com/journals/ja/2010/510380.html#B10) ]. Despite evidence

that indoor

dampness/moldiness is associated with respiratory conditions, little is known

about the contribution of indoor mold levels to allergic sensitization

rates [_13_ (http://www.hindawi.com/journals/ja/2010/510380.html#B13) , _14_

(http://www.hindawi.com/journals/ja/2010/510380.html#B14) ].

Hurricane Katrina struck the New Orleans area in August 2005. Widespread

damage resulted in substantial environmental degradation. In New Orleans, 80%

of the city and 120,000 homes flooded [_15_

(http://www.hindawi.com/journals/ja/2010/510380.html#B15) , _16_

(http://www.hindawi.com/journals/ja/2010/510380.html#B16) ]. Exposure

assessments after the storm detected

culturable levels of indoor mold at concentrations between 22,000 to

515,000 CFU/m3,

well above the threshold associated with adverse health effects [_15_

(http://www.hindawi.com/journals/ja/2010/510380.html#B15) –_17_

(http://www.hindawi.com/journals/ja/2010/510380.html#B17) ]. Mycotoxins have

been detected

in home dust samples two years after the storm [_18_

(http://www.hindawi.com/journals/ja/2010/510380.html#B18) ]. These data coupled

with qualitative

reports of increased respiratory and allergic illness in the general

population led to concern about adverse effects of exposure to mold both in the

short term and in the long term [_19_

(http://www.hindawi.com/journals/ja/2010/510380.html#B19) ]. Despite evidence of

increased ambient exposure and

qualitative reports of increased allergic response, to our knowledge there has

been no study assessing the relationship between the two.

***********Additionally, the long term effect of living in an environment

subsequent to massive flooding remains undescribed*******************.

The purpose of this study was to examine the relation between reported

exposure to mold/dampness and mold-specific allergic sensitization among

residents of the Greater New Orleans area following Hurricane Katrina. The

hypothesis being tested is that persons with higher levels of mold or dampness

exposure are more likely to be mold sensitized than those with lower levels

of exposure and that due to the extent of exposure the prevalence of mold

reactivity in the Greater New Orleans area would exceed the national

average.

2. Materials and Methods

We conducted a 3-year study of patients presenting to the Allergy, Asthma

and Immunology clinic of the Ochsner Health System, a major medical facility

in the New Orleans area. The source population was patients receiving a

skin prick test between December 1, 2005 and December 31, 2008. Any patient

skin prick tested for mold reactivity was eligible for the study. Skin prick

testing on patients presenting to the Clinic is performed to evaluate

potential allergic disease in patients complaining of respiratory difficulty,

rhinitis, conjunctivitis, cough, wheezing, or dypsnea. Patients presenting

to the clinic between January 1, 2008 and December 31, 2008 were

prospectively recruited by clinic nurses. Patients who underwent skin prick

testing

between December 2005 and December 31, 2007 were retrospectively recruited

via mail using contact information contained in clinic records. All eligible

participants received up to three recruitment letters and a recruitment

postcard encouraging participation in the study. Those agreeing to participate

completed an informed consent and an exposure assessment survey.

2.1. Exposure Assessment

Exposure to mold or dampness in both the home and workplace was assessed

via survey questionnaire. Questions were adapted from validated survey tools

and measured exposure through multiple domains [_20_

(http://www.hindawi.com/journals/ja/2010/510380.html#B20) –_22_

(http://www.hindawi.com/journals/ja/2010/510380.html#B22) ]. Questions relevant

to exposure and pertinent to

Hurricane Katrina (e.g., number of residences and extent of damage) were

also included on the exposure assessment questionnaire.

Using a standard mold/dampness self-reported exposure format, participants

were asked the following five exposure questions; since Hurricane Katrina

(1) have you observed water damage, water leaks, damp stains, standing

water, or condensation in the home, (2) have you noticed a musty odor in your

home, (3) have you observed mold or mildew in your home, (4) have you

observed mold or mildew inside your workplace, (5) have you worked in an

occupation where you were regularly exposed to mold. To assess length of

exposure,

participants were asked to estimate the number of months associated with

each of the five exposures listed above. Questions regarding the extent of

hurricane-related damage, renovation activity, and use of personal protective

equipment were also included. Extent of home repair was measured on an

ordinal scale; need for repair, repairs only (painting or cleaning only),

material repairs (painting or cleaning plus new carpet, sheetrock, etc.),

and repairs (part or all of the house gutted). Finally, questions were asked

about previous allergy testing, prevalence of asthma, and the nature of

previous visits to the Ochsner Allergy clinic.

Exposure was assessed three ways. First, an ordinal scale was constructed

similar to the one used by Engvall et al. and based on the number of “yesâ€

responses to the five exposure questions [_23_

(http://www.hindawi.com/journals/ja/2010/510380.html#B23) ]. Exposure was also

categorized as either

minimally exposed (yes to one exposure question), moderately exposed (yes to 2

or 3 questions), or highly exposed (yes to 4 or 5). Finally, the total

months of exposure from all five questions was used as a continuous variable

for exposure. We also looked at renovation activities as a potential source

of mold exposure. The mean number of months spent renovating a home or

living in a home while it was being renovated was assessed along with the use

of personal protective equipment.

2.2. Skin Testing

Mold allergens used for testing included Acremonium, Alternaria alternata,

Aspergillus fumigatus, Botrytis cinerea, Candida albicans, Chaetomium

globosum, Cladosporium cladosporioides, Curvularia spp., Epicoccum nigrum,

Fusarium ssp., Gliocladium, Helminosporium, Mucor spp., Neurospora spp.,

Nigrospora spp., Penicillium Mixed, Phoma herbarum, Pullularia pullulans,

Rhizopus spp., Rhodotorula rubra, Smuts Mixed, Stemphyllium spp., Trichoderma,

and Trichophyton mentagrophytes. All extracts were glycerinated and supplied

by ALK-Abello, Inc. (Round Rock, TX, USA) in a 1 : 20 weight/volume

concentration except Gliocladium (1 : 20 weight/volume) and Trichoderma

(1 : 

40 weight/volume) were supplied by Greer Labs (Lenoir, NC, USA). Histamine

(10 mg/ml) and saline were used as positive and negative controls. Drops of

the allergens were applied to the back and a single lancet (AccuSet,

Alk-Abello, Inc., Round Rock, TX) was passed through each drop to prick the

skin.

Tests were read 15 minutes later using the following scale: negative, 1+

(erythema only), 2+ erythema with wheal 3 mm, 3+ erythema with wheal 3 mm,

and 4+ Erythema with pseudopods. Cases of positive mold reactivity were

defined as a wheal diameter 3 mm to any mold genera.

2.3. Statistical Analysis

The analysis involved descriptive statistics, unadjusted estimates and

tests of, including chi-square and -tests, crude odds ratios and 95%

confidence intervals, and modeling techniques to adjust for relevant

covariates.

Logistic regression methods were used to determine the relationship between

the mold positivity and dampness/mold exposure, controlling for potential

covariates.

3. Results

A total of 529 patients presenting to the Allergy and Immunology clinic

between December 1, 2005 and December 31, 2008 were tested for mold reactivity

and completed an exposure assessment questionnaire. Demographic,

residential, and clinical characteristics of the study population are described

in

Table _1_ (http://www.hindawi.com/journals/ja/2010/510380.tab1.html) . The

majority of participants were white (78.7%) and female (67.1%). The median

age was 44 years and participants ranged in age from 1 to 93 years.

Forty-seven percent of respondents lived in at least two residences since

Hurricane

Katrina. Over half (53.3%) of respondent homes required at least surface

material repairs. Over half (56.7%) of all patients tested positive to at

least one allergen. Thirty-four percent tested positive to either Der p1 or

Der f1; 27.6% to any tree pollen; 22.5% to any weed pollen; 26.6% to any

grass pollen. Doctor diagnosed asthma was reported by 27.6% of study

participants. The mold sensitization rate was 10.4% and 14.9% among all

participants

and asthmatics, respectively. A list of mold specific positive reactions

and the number of people testing positive to each mold is detailed in Table

_2_ (http://www.hindawi.com/journals/ja/2010/510380.tab2.html) .

(http://www.hindawi.com/journals/ja/2010/510380.tab1.html)

Table 1: Characteristics of the study population ().

(http://www.hindawi.com/journals/ja/2010/510380.tab2.html)

Table 2: Results of SPT for mold and the number of persons testing

positive to each mold.

The frequency of mold/dampness by exposure category is described in Table

_3_ (http://www.hindawi.com/journals/ja/2010/510380.tab3.html) . Water leaks,

condensation, water damage, damp stains, or standing water was observed by

34.5% of the study population with a mean observation time of 9.1 months.

A musty odor was reported by 27.4% (mean number of months 9.6) and observed

mold or mildew reported by 29.8% (mean number of months observed 10.0) of

the study population. Using an ordinal scale, 103 people (19.5%) answered

yes to one of the exposure questions, 86 (16.3%) answered yes to two of the

exposure questions, 80 (15.1%) answered yes to three of the exposure

questions, 19 (3.6%) answered yes to four of the exposure questions, and 9

(1.7%)

answered yes to all five exposure questions. In the workplace, 18.7% of

respondents observed mold or mildew with a mean observation time of 14.1

months. Approximately, 12% of respondents reported regularly working in an

occupation with mold (mean 15.2 months). After totaling the number of months

exposed to each of the exposure questions, the mean number of months of

exposure to any of the dampness indicators in either the home or workplace was

13.3.

(http://www.hindawi.com/journals/ja/2010/510380.tab3.html)

Table 3: Dampness/mold in the home or workplace of study participants ().

Residential renovation activities are described in Table _4_

(http://www.hindawi.com/journals/ja/2010/510380.tab4.html) . 163 people (31.3%)

reported

living inside a home while it was being renovated and half () took part in

some type of renovation activity, although when asked what kind, the data

were largely missing. Of those who took part in renovation activities, 119

people (48.6%) reported that they wore personal protective equipment at

least 50% of the time; 32.7% reported no personal protective equipment use

despite engaging in renovation work.

(http://www.hindawi.com/journals/ja/2010/510380.tab4.html)

Table 4: Residential renovation activities.

The relation between mold/dampness and mold reactivity was first assessed

for each question individually. None of the exposures was individually

related to the outcome (data not shown). Multivariable logistic regression

models were run to assess the association between mold/dampness and mold

positivity adjusting for age, gender, and asthma status (Table _5_

(http://www.hindawi.com/journals/ja/2010/510380.tab5.html) ). In adjusted

models, the

relationship between mold/dampness exposure and cases of mold positive was

nonsignificant whether exposure was measured on an ordinal scale (), or

categorical scale (minimal exposure ; moderate exposure ; high exposure ).

When

exposure was expressed as the total months of exposure to any of the five

mold/dampness variables, the relationship was also nonsignificant (;

95%  –

1.01; ).

(http://www.hindawi.com/journals/ja/2010/510380.tab5.html)

Table 5: Multivariable analysis of mold/dampness indicators and allergic

sensitization to mold adjusted for age and gender.

4. Discussion

When the federally built flood protection system failed, the New Orleans

area was inundated by floodwaters. The majority of the population evacuated

and returned to homes with varying degrees of flood damage. Over half of

study respondents’ homes had enough damage to require substantive repair. On

average, respondents reported exposure to any of the dampness indicators for

13 months. The role of indoor dampness in triggering and exacerbating

asthma and other respiratory symptoms has been documented in numerous studies;

however, there is limited data on the relation of indoor dampness to mold

sensitivity, particularly in populations living in areas with significant

flooding events. The results of this analysis failed to find a significant

relationship between any of the measures of mold/dampness exposure and

sensitivity to mold allergens either in unadjusted or adjusted models.

Furthermore, when asthma status was considered in the model, the results did

not

materially change. Thus, the finding of no association was robust across

measures of exposure and across the study population. Although direct pre-post

storm comparisons cannot be made, to explore the possibility that mold

sensitivity was higher than expected in New Orleans residents, we compared our

estimates to those obtained from general population estimates. To our

surprise, we found the mold reactivity rate of 10% found in our sample equaled

the

rate in the general U.S. population [_5_

(http://www.hindawi.com/journals/ja/2010/510380.html#B5) ]. Further, among

asthmatics, the prevalence of mold

reactivity, at 14.9%, was lower than rates found in both the general

population and in other atopic populations [_5_

(http://www.hindawi.com/journals/ja/2010/510380.html#B5) , _24_

(http://www.hindawi.com/journals/ja/2010/510380.html#B25) ].

Exposure to molds and fungi can elicit a nonallergic response in persons

not sensitized to mold/fungi allergen, with respiratory symptoms that are

similar to those with an allergic response. Epidemiological studies in adults

have shown comparable associations between home dampness and the occurrence

of respiratory symptoms among allergic and nonallergic subjects,

suggesting that damp-related symptoms in adults are not necessarily promoted by

atopy [_13_ (http://www.hindawi.com/journals/ja/2010/510380.html#B13) ]. Other

studies, however, have shown a higher respiratory response and/or asthma

diagnosis in those sensitized to mold allergen or with atopic heredity in

relation to mold allergen [_7_

(http://www.hindawi.com/journals/ja/2010/510380.html#B7) ]. Numerous reports of

adverse health effects and reports of

increased visits to health care providers due to allergic responses attributed

to

moldy environs have been reported in the post-Hurricane Katrina

environment. It is possible that these persons experienced a nonallergic

respiratory

response to mold exposure which would not be captured by this design.

A limitation of the study is participant selection. Due to population

fluctuation in the years immediately following Hurricane Katrina,

retrospectively contacting patients was a challenge. The overall response rate

was 52%.

There was no way to determine whether the address recorded at the time of

the clinic visit was relevant at the time the study was conducted. Therefore,

the reason for nonresponse is unknown. While lower than optimal response

rates may have introduced selection bias, analysis of responders versus

nonresponders revealed no differences in sensitivity profile, age, gender,

race, or geographic location. Another limitation is that minorities and those

without health insurance are underrepresented, limiting the generalizability

of study findings. Although over half the study subjects’ homes incurred

significant hurricane damage, survey data indicate the majority of

respondents did not live for long periods of time in their homes during

renovation.

Due to the extent of damage incurred in most flooded homes, it seems

reasonable that this pattern of habitation would reflect the general population

experience. However, people at highest risk for mold sensitivity may be

those with limited incomes who could not afford to stay out of their houses for

long periods of time, who did significant amounts of renovation work, and

who may not have access to health care. Studies targeting this

subpopulation are needed. Finally, a potential limitation of this study is

self-report

of mold/dampness/musty exposure. However, our exposure assessment tools

have been shown to be associated with objective measures in numerous studies

and given that the findings were consistent for all three methods of

exposure assessment utilized, the likelihood that information bias is

responsible

for our findings is minimized [_5_

(http://www.hindawi.com/journals/ja/2010/510380.html#B5) , _22_

(http://www.hindawi.com/journals/ja/2010/510380.html#B22) , _23_

(http://www.hindawi.com/journals/ja/2010/510380.html#B23) ].

This study provides important information on the health of residents living

in an area after widespread damage due to flooding. Over half the study

population had significant home damage, 34% reported dampness/mold in their

home, half reported engaging in renovation activities, and approximately

one-third lived in a home undergoing renovation. Earlier research confirmed

that potential exposure was high; both the indoor and outdoor environments

were found to have extremely high fungal spore concentrations [_15_

(http://www.hindawi.com/journals/ja/2010/510380.html#B15) , _16_

(http://www.hindawi.com/journals/ja/2010/510380.html#B16) , _25_

(http://www.hindawi.com/journals/ja/2010/510380.html#B26) ] prompting concern

about development of mold

sensitivity in the general population. Despite these concerns, the mold

sensitivity rate was found to be typical of the population at large and was not

found to be related to the amount of home damage or exposure to

mold/dampness in the home. A strength of the study was the extensive exposure

assessment which included duration of exposure in all households occupied over

the

course of the study as well as workplace exposure. Alternate explanations

for the negative findings include lack of power due higher than anticipated

exposure rates in both groups, 60% and 55.7% in disease and nondiseased,

respectively, a nonatopic response or less than anticipated resident exposure

because of the severity of flooding. This paradoxical situation of a

protective effect of flooding may have occurred because homes were so badly

damaged that they were uninhabitable until gutting mold contaminated material

was complete.

5. Conclusion

We did not find elevated prevalence of mold sensitivity among those living

in damp/moldy homes. Direct comparisons of mold sensitization rates pre-

versus post-hurricane Katrina cannot be made in this study due to lack of

pre-storm data, however, when comparing the overall rate of mold sensitivity

in New Orleans to general population data and rates from similar sampling

frames, we did not find an excess rate [_5_

(http://www.hindawi.com/journals/ja/2010/510380.html#B5) , _24_

(http://www.hindawi.com/journals/ja/2010/510380.html#B25) ]. These results along

with results of earlier research [_26_

(http://www.hindawi.com/journals/ja/2010/510380.html#B27) ] indicate no

excess risk of adverse health effects in residents returning to live in New

Orleans after the devastation of Hurricane Katrina.

Acknowledgment

This paper was sponsored by RAND Gulf States Policy Institute by a grant

provided by the Pew Charitable Trust Foundation.

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In a message dated 11/5/2010 4:51:02 P.M. Pacific Daylight Time,

dragonflymcs@... writes:

.. Conclusion

We did not find elevated prevalence of mold sensitivity among those living

in

damp/moldy homes. Direct comparisons of mold sensitization rates pre-

versus

post-hurricane Katrina cannot be made in this study due to lack of

pre-storm

data, however, when comparing the overall rate of mold sensitivity in New

Orleans to general population data and rates from similar sampling frames,

we

did not find an excess rate [5, 24]. These results along with results of

earlier

research [26] indicate no excess risk of adverse health effects in

residents

returning to live in New Orleans after the devastation of Hurricane

Katrina.

_http://www.hindawi.com/journals/ja/2010/510380.html_

(http://www.hindawi.com/journals/ja/2010/510380.html)

God Bless !!

dragonflymcs

Mayleen

[Guest guest]

I know that is why I posted it :   it is a joke, the paper.  The other I

posted

paid for by Clorox  

 

God Bless !!

dragonflymcs

Mayleen

________________________________

From: " snk1955@... " <snk1955@...>

Sent: Fri, November 5, 2010 8:02:35 PM

Subject: Re: [] The Relationship between Mold Exposure and Allergic

Respo...

 

Mayleen,

You need to read that paper in detail. The gist is that they only

included those who had health insurance in the study and only looked for IgE

response as an indicator of illness. That paper is full of double speak.

[Guest guest]

Sorry, I missed the Clorox part.. too funny. (or maybe not!) D

>

> I know that is why I posted it :   it is a joke, the paper.  The other I

posted

> paid for by Clorox  

>  

>

> God Bless !!

> dragonflymcs

> Mayleen

>

> ________________________________

> From: " snk1955@... " <snk1955@...>

>

> Sent: Fri, November 5, 2010 8:02:35 PM

> Subject: Re: [] The Relationship between Mold Exposure and

Allergic

> Respo...

>

>  

> Mayleen,

>

> You need to read that paper in detail. The gist is that they only

> included those who had health insurance in the study and only looked for IgE

> response as an indicator of illness. That paper is full of double speak.

>