Damp Indoor Space and Your Patient : What’s Mold Got To Do With It?

1. Damp Indoor Space and Your Patient :What’s Mold Got To Do With It? Carl Baum, MD, FAAP, FACMT Associate Professor of Pediatrics Yale University School of Medicine Director, Center for Children’s Environmental Toxicology Yale-New Haven Children’s Hospital Marian L Heyman, MT (ASCP), MPH Epidemiologist/Industrial Hygienist Coordinator, Indoor Environmental Quality Prg Environmental Epidemiology & Occupational Health Program Connecticut Dept. of Public Health 1

3. DISCLOSURE

4. Case • 15-year-old girl presents to your office • Complains of acutely increased WOB • History: • “I’m allergic to mold” • Petitioned last year to change schools • Re-entered old school for a rehearsal • Became acutely short of breath

5. Case • 15-year-old girl • Increased WOB • Physical Exam: • Anxious, hyperventilating • T = 37 C P = 90 RR = 45 BP = 130/70 • Room air oxygen saturation = 100% • Chest: CTA without wheeze; good aeration

6. Case • 15-year-old girl • Increased WOB • Assessment? • Plan?

7. Mycology Basics • Yeasts • Unicellular • Round, globose • Most reproduce by budding Fungi = yeasts and mold • Mold • Multicellular, filamentous • Filaments - hyphae • “mat” of hyphae = mycelium • Reproduce from fruiting body via conidia (spores) which can become airborne 7

8. Fast Facts About Fungi Lack chlorophyll Depend on external food sources Must have water to grow! Thousands of fungal species Ubiquitous in nearly all environments “But before you move to Antarctica, remember that mold spores also grow indoors, making it a year-round problem.” Asthma & Allergy Foundation of America 8

9. Fast Facts About Fungi Fungal cell walls contain 1-3-ß-d-Glucan, which can cause inflammation. Spores & mycelium contain allergens; most have not been chemically characterized Many of the known fungal allergens are proteins found in fairly high concentrations in the spores. 9

10. Fungal spores size range: 1 to 50 ųm. Humidity can affect size Spores < 10 ųm can be deposited in alveoli; smaller can be swallowed Lower airway deposition for 5 ųm particles is six times higher in newborns than in adults (Phalen and Oldham 2001) The spores in some species contain low molecular weight chemicals that are cytotoxic [mycotoxins] Fast Facts About Fungi Alternaria spores Penicillium sp. Stachybotris spores Cladosporium spores 10

11. Most belong to phylum Deuteromycota, or Fungi Imperfecti Medically Important Fungi Disease Ranges: Superficial mycoses with no pathological changes to systemic mycoses- invasive, lethal Lung Tissue: Fungal Pneumonia- Aspergillus fumigatus Note septate hyphae, dichotomous branching Aspergillus fumigatus 11

12. Opportunistic Fungi Almost exclusively affect debilitated patient Allergy in pts w/ underlying respiratory conditions i.e., asthma or cystic fibrosis Opportunistic infections in immunocompromised pts Enter buildings on our clothes, shoes, pets, windows, doors, mechanical ventilation systems Indoor Environmental Fungi 12

13. Mold Is In Every Home In The USA Just because mold is found in a building, it doesn’t mean everyone will be exposed or become symptomatic. In order to be exposed, people must either: • Inhale airborne spores or fungal byproducts • Skin contact (dermal exposure) • Eat it (ingestion) 13

14. What are the Reported Health Effects? • Allergic • Infectious • Toxic

15. Allergic • 10% of population has antibodies to fungal antigens • 5% expected to show clinical illness • allergic asthma • allergic rhinitis (“hay fever”) • Hypersensitivity pneumonitis • more serious but rare • Outdoor molds more abundant

16. Infectious • Benign tinea • …pedis, cruris, corporus, onychomycosis • Pathogenic • Blastomyces • Coccidioides • Cryptococcus • Histoplasma

17. Toxic • Secondary metabolites (mycotoxins) • not required for survival of fungus • Clinical use • PCN, CSA • Inhalation • blamed for numerous non-specific symptoms

18. MMWRJanuary 17, 1997 / 46(02);33-35 Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants -- Cleveland, Ohio, 1993-1996 In November 1994, private physicians and public health officials in Cleveland, Ohio, and CDC reported a cluster of eight cases of acute pulmonary hemorrhage/ hemosiderosis that had occurred during January 1993-November 1994 among infants in one area of the city (1). Two additional cases were identified in December 1994. All 10 infants lived within seven contiguous postal tracts in eastern metropolitan Cleveland. Pulmonary hemorrhages recurred in five of the infants after they returned to their homes shortly after hospital discharge; one infant died as a result of pulmonary hemorrhage.

19. Acute Idiopathic Pulmonary Hemorrhage • Cluster of 10 infants in Cleveland • 1 or more hemorrhagic episodes • 1 death • CDC case-control study identified 2 associations

20. Case-control Study • Major associations • Major water damage in previous 6 months • Increased levels of Stachybotrys chartarum • Hypothesis • AIPH may be caused by mycotoxins • “further research is needed to determine causal[ity]”

21. Case-control Study • Findings cited in • Environmental health guidelines • Congressional testimony • Popular media

22. August 12, 2001

23. “Haunted by Mold” • Melinda Ballard • Dripping Springs, TX • “…she pulls out two portable respirator masks. “These won’t screen out all the mycotoxins,” she warns as she tosses one to me. “That’s the dangerous stuff, so we’ll only stay a few minutes.”

24. “Haunted by Mold” • 4-year-old son became ill • “coughing up blood” • “equilibrium…completely shot” • “very bad stomach problems” • vomiting, diarrhea • “…it just spanned the whole globe in terms of symptoms.”

25. Arizona Republic, 1/11/02

26. “Mold Kids” • 12 teens from Amity High and Jr High, CT • Many homebound or transferred to other schools because of “mold-related symptoms” • “respiratory distress” • “…still suffers from a sinus infection as a result of her time at [Amity] Junior High.” Orange Bulletin, 4/14/04

29. Review of AIPH Investigation • Reported OR of 9.8 for change of 10 CFU/m3 • Statistically unstable and potentially inflated • OR =1.5? • Sampling • Not blinded (2x in case homes) and aggressive • Water-damage classification • Little difference in airborne S. chartarum levels • Unrecognized correlate of water damage?

30. Review of AIPH Investigation • Evidence not of sufficient quality to support an association between AIPH and S. chartarum • Clusters of AIPH have not been reported in other flood-prone areas where S. chartarum and other toxigenic fungi might be favored

31. Evidence-based Medicine • ACOEM (2002) • IOM (2004) • WHO (2009)

32. ACOEM • 2002 evidence-based statement • Current scientific evidence does not support causal relationship between inhaled mycotoxins and adverse health effects

33. Evidence-based Medicine • CDC request • Institute of Medicine (IOM) • Committee on Damp Indoor Spaces and Health

34. IOM • 2004 Report • 341 pages

35. Damp Indoor Spaces:Categories of Evidence • Sufficient evidence of a causal relationship • Sufficient evidence of an association • Limited or suggestive evidence of an association • Inadequate or insufficient evidence to determine whether an association exists

36. Health Outcomes vs Mold • Sufficient evidence of a causal relationship • Sufficient evidence of an association • Limited or suggestive evidence of an association • Inadequate or insufficient evidence to determine whether an association exists

37. Health Outcomes vs Mold • Sufficient evidence of a causal relationship:

38. Health Outcomes vs Mold • Sufficient evidence of a causal relationship: No outcomes met definition

39. Health Outcomes vs Mold • Sufficient evidence of a causal relationship • Sufficient evidence of an association • Limited or suggestive evidence of an association • Inadequate or insufficient evidence to determine whether an association exists

40. Health Outcomes vs Mold • Sufficient evidence of an association: Upper respiratory tract symptoms Asthma in sensitized asthmatics Hypersensitivity pneumonitis (susceptible) Wheeze Cough

41. Health Outcomes vs Mold • Sufficient evidence of a causal relationship • Sufficient evidence of an association • Limited or suggestive evidence of an association • Inadequate or insufficient evidence to determine whether an association exists

42. Health Outcomes vs Mold • Limited or suggestive evidence of an association: Lower respiratory illness in otherwise-healthy children

43. Health Outcomes vs Mold • Sufficient evidence of a causal relationship • Sufficient evidence of an association • Limited or suggestive evidence of an association • Inadequate or insufficient evidence to determine whether an association exists

44. Health Outcomes vs Mold • Inadequate or insufficient evidence to determine whether an association exists: 1/3 Dyspnea Airflow obstruction (otherwise healthy) Mucous membrane irritation syndrome Chronic obstructive pulmonary disease Inhalational fevers (non-occupational)

45. Health Outcomes vs Mold • Inadequate or insufficient evidence to determine whether an association exists: 2/3 Lower respiratory illness (healthy adults) Rheumatologic / other immune disease Acute idiopathic pulmonary hemorrhage Skin symptoms Asthma development

46. Health Outcomes vs Mold • Inadequate or insufficient evidence to determine whether an association exists: 3/3 Gastrointestinal tract problems Fatigue Neuropsychiatric symptoms Cancer Reproductive effects

47. “Toxic Mold”

48. Indoor Mold • Molds blamed for variety of ailments and disabilities • Subject of litigation • Ballard case: $32 million

49. DPH Message 49

50. If It Looks Like Mold & Smells Like Mold… 50