ALBERT F. ROBBINS, D.O., MSPH-FAAEM-CIEBOARD CERTIFIED: OCCUPATIONAL/ENVIRONMENTAL MEDICINEMOLDSLIDESHOWFINALCORRECTED5 ALLERGYCENTER.COM 420 W. HILLSBORO BLVD., DEERFIELD BEACH, FL 33441ALBERTROBBINS@AOL.COM954-421-1929BUILDING RELATED HEALTH PROBLEMS

BUILDING RELATED HEALTH PROBLEMSOVERVIEW:1)HEALTH EFFECTS OF POLLUTANTS 2)BUILDING DESIGN FLAWS3)OCCUPANT FACTORS4)BUILDING RELATED DISEASES 5)ENVIRONMENTAL MEDICINE APPROACHES & TREATMENTS6)PUBLIC HEALTH GUIDELINES

BUILDING RELATED HEALTH PROBLEMS UNTRAINED PHYSICIANS - dont know that they dont knowBUILDING RELATED SYMPTOMS - usually nonspecific, multisystemINDUSTRIAL HYGIENISTS multiple exposures, complex interactionsBUILDING OWNERS - not recognizing potential health risks

SPECIFIC BUILDING RELATED AGENTSALLERGENSIRRITANTS-VOCSBACTERIA & VIRUSESTOBACCO SMOKEPESTICIDES

WOOD DUSTCOPY PAPER, FIBERGLASS, LASER TONERS FORMALDEHYDEASBESTOSRADON

BUILDING RELATED HEALTH COMPLAINTSDISCOMFORTIRRITATIONHEADACHEFLU-LIKESKIN RASHESFATIGUEALLERGYASTHMACOUGHINFECTIONCOGNITIVEDYSFUNCTION

BUILDING RELATED SYMPTOMSTARGET ORGANS VARY BASED ON OCCUPANT FACTORSA MULTIFACTORIAL CUMULATIVE THRESHOLD EFFECTINFLAMMATION

HIGH INFLAMMATORY MEDIATORSFOUND IN NASAL FLUIDS OF PERSONS IN DAMP BUILDINGSMITES, BACTERIA, MOLDS, ENDOTOXINS ALL CONTRIBUTEMINIMIZED BY HUMIDITY & MOISTURE CONTROL IN BUILDINGS

ENDOTOXIN-LIKE IRRITANTS(1-3 )B-D GLUCANS are ENDOTOXIN-like substances that may be irritating & stimulate the immune systemSeveral studies have implicated GLUCANS as causal factors in SBS and NSBRI

CAUSES OF BUILDING RELATED SYMPTOMS CHEMICAL VOLATILES - VOCsPOOR VENTILATION & AIRFLOW POOR CLIMATE CONTROLAIRBORNE MICROORGANISMSALLERGENSSYNERGISM of MULTIPLE POLLUTANTS & POOR VENTILATION

INDOOR vs. OUTDOOR AIRLOW VENTILATION RATERECIRCULATED AIRBUILD-UP OF POLLUTANTSULTRAVIOLET LIGHTTEMPERATURE EXTREMESDILUTED AIR An ounce of fresh air equals a pound of indoor air

INDOOR POLLUTANT CONCENTRATION FACTORSEMISSION RATES OF POLLUTANTS INDOORSVENTILATION RATEOCCUPANT BEHAVIOR

INDOOR HEALTH PROBLEMS "No common air from without is as unwholesome as the air within a closed room that has been often breathed and not changed." Ben Franklin

SICK BUILDING SYNDROME symptomsNEUROTOXIC EFFECTSMUCOUS MEMBRANE IRRITATIONRESPIRATORY SKIN CHEMOSENSORY CHANGESsymptoms usually subside on leaving the building ;NOT linked to any specific pollutant or illness

BUILDING RELATED ILLNESSSYMPTOMS DONT always LEAVE when leaving the buildingSYMPTOMS can be LINKED to EXPOSURE to chemical, biological, allergic or toxic substances

BUILDING RELATED ILLNESSESINFECTIOUS DISEASESPESTICIDE POISONINGCARBON MONOXIDERHINITIS & SINUSITIS ASTHMA

HYPERSENSITIVITY PNEUMONITISNOSOCOMIAL INFX CONTACT DERMATITIS

HEALTH EFFECTS OF POLLUTANTSIRRITATION AIRWAY & NEUROGENIC INFLAMMATION ALLERGY- ASTHMA, RHINITIS, URTICARIA OR HIVES, ALLERGIC ALVEOLITIS (HP); MULTISYSTEMTOXIC REACTIONS -TARGET ORGANS VARY-MULTISYSTEMINFECTIONS

ALLERGYTHE GREAT MASQUERADERTHE LONG COLDINFLAMMATION ANYWHEREIMMEDIATE AND DELAYED REACTIONS

CUMULATIVE THRESHOLD EFFECTINFECTION COEXISTSTOXICITY OVERLAPS

ALLERGIC TRIADEDEMAMUCOUS PRODUCTIONSMOOTH MUSCLE SPASM

*ANYWHERE IN THE BODY;SITE SWITCHING OCCURS

TYPES OF ALLERGIC REACTIONSTYPE 1 IGE RAPID;ANAPHYLAXIS TYPE 2 IGG - Minutes to hoursTYPE 3 IGG - Immune complexes-Hours to daysTYPE 4 IGG- Lymphocyte mediated - weeks to months

CHEMICAL ALLERGYHAPTEN INDUCEDIGE-IMMEDIATEIGG-DELAYEDMISDIAGNOSISCONTROVERSY

IRRITANT EFFECTMULTIPLE MECHANISMS POORLY UNDERSTOOD

FORMALDEHYDECHEMICALLY INDUCED IMMUNE SYSTEM DYSREGULATIONALLERGY & TOXICITY MAY OVERLAPMOBILE HOME SYNDROMEUFFI;PARTICLEBOARD;CLOTHING STORES

PERCHLOROETHYLENEARRHYTHMIASHORTNESS OF BREATHVAGUE NEUROLOGIC SYMTOMSSOLVENT LIKE ENCEPHALOPATHY

*DRY CLEANING STORES

METHYLENE CHLORIDEVARNISH REMOVER used in poorly ventilated spacesCONVERTED TO CARBON MONOXIDECAUSES CORONARY ARTERY SPASMSYMPTOMS OF HEART ATTACK AND LOSS OF CONSCIOUSNESS

PARADICHLOROBENZENEAIR FRESHENERSPLUG INSCLEANING CHEMICALSINCREASES POLLUTANT LOADVOLATILE ORGANIC COMPOUND

HEXACHLOROBENZENEANEMIA IN 2 YEAR OLDPOISONED BY DOG FLEA DIPCHEMICALLY INDUCED ILLNESS!HIGHER SUSCEPTIBILITY IN CHILDRENBUILDING RELATED!

VOLATILE ORGANIC COMPOUNDS-VOCsCARPETS, PAINTS, CLEANING SOLUTIONS, AIR FRESHENERS, LYSOL, PLASTICSSOLVENTS AND PESTICIDES PERFUMES

MICROBIAL VOLATILE ORGANIC COMPOUNDS CAUSE OCCUPANT DISCOMFORT VOCS ARE MUCOUS MEMBRANE IRRITANTS CAN IRRITATE THE AUTONOMIC NERVOUS SYSTEM

MOLD VOCSWhat SMELLS in a basement, closet or carpetthe ODOR in a musty building or apartmentMore than 500 VOC's have been identified from many different FUNGI

MOLD VOCs- ARE CHEMICALS!ACETALDEHYDEACETONEHEXANEBENZENESTYRENE

ETHANOLSCARBON DISULFIDEISOPROPANOLS

MOISTURE increases risk of AIRBORNE DISEASEDUST MITES grow: bedding, upholstered & soft furnishings COCKROACH, ENDOTOXINS,AND MOLDS MOLD VOCS MYCOTOXINS

CAUSES OF MOISTURE HVAC SYSTEM FAILURESROOF LEAKSOPERATIONAL PERSONAL NEGLECTHURRICANES & FLOODSCONSTRUCTION FLAWSPIPE BURSTSSEWAGE WATER BACKUP

MICROBIAL AGENTSRECENT IAQ STUDIES SUGGEST -MICROBIAL CONTAMINATION UNDERESTIMATED - microorganisms 35% to 50% of casesVISUAL INSPECTION & SMELL-DIAGNOSTIC(1000-10000 CFUS VIEWED WITH CONCERN-SAMPLING?)

MICROBIAL AGENTS

WHEREVER DIRT, WATER, HEAT AND AIR COINCIDEAIR SAMPLING UNNECESSARYERADICATE THE RESERVOIR THROUGH MOISTURE PREVENTION & CLEANING

VIABLE BACTERIAFOUND IN SICK BUILDINGSActinomycetesMicrospora faeniStaphylococcus StreptococcusPseudomonas species(ALSO LEGIONNELLA AND TB)

(Austwick et al, 1989 - SBS Studies)

NOSOCOMIAL INFECTIONMRSAPSEUDOMONAS

HOSPITAL INFECTIONS IN IMMUNOCOMPROMISED PATIENTS

MOLDS & FUNGI Reproduce by producing spores which can easily become airborne

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MOLDS OR FUNGI FUNGI include mushrooms, mildews, molds & yeast More than 1,000 different KINDS of molds have been identified indoors200 pathogenic species identified

MOLDS & FUNGITypically grows slower than bacteriaSpores size varies - 1.5 microns to 200 micronsSpore sizes in water damaged environments typically are 1.0 to 10 microns (particles 10 microns & below are respirable) 2-2

FUNGI TWO BASIC TYPES OF SPORESDry sporesAspergillusPenicilliumThese spores are easily disturbed and become airborne (bioaerosol)

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FUNGI TWO BASIC TYPES OF SPORESSlimy sporesFusariumStachybotris (likes to grow on cellulose)

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STACHYBOTRIS:TOXIC MOLDGreenish black SLIME moldRequires VERY WET conditions to growHidden within building envelopeCapable of producing a very potent MYCOTOXIN - TRICOTHECENENot easily airborne until DRY

SOURCES OF MOLD IN BUILDINGSWallboardCeiling tilesInsulationDuct workAir handling unitsCarpetingHumidifiersPlantsOutdoor air

MOLDS GROW ON ClothCarpet Leather WoodInsulation Foodswhen moist conditions exist

FUNGAL CONTAMINATED ITEMSFoodsBooksPapersFurniturePianosBeddingFabric WallpaperCurtainsClothing Stuffed AnimalsHair PiecesCarpetsPlantsArtificial PlantsBathroomsClosetsTVsAir ConditionersHumidifiersDehumidifiersIce MachinesDishwashersStovesDrip PansRefrigeratorsMachine PartsOld Motor Driven Equipment

MOLD IMPACT ON HUMAN HEALTH DEPENDS ONThe MOLD SPECIES involvedMetabolic PRODUCTS producedIndividual EXPOSURE amount & durationINDIVIDUAL SUSCEPTIBILITY

HUMAN EXPOSURE TO MOLDS & PRODUCTSTOUCH, BREATHE OR EAT IT (Surface contact, air or food)SPORES, MICROBIAL VOCs, MYCOTOXINS

AEROBIOLOGIC EXPOSURE PATHWAYSOURCE: Can it SURVIVE & MULTIPLY?AEROSOL: Can it become AIRBORNE in sufficient QUANTITY?EXPOSURE: Can it remain VIABLE long enough to cause disease?RESPONSE: Can it be INHALED by a susceptible host?

INCREASED HEALTH RISK-- The Susceptible PopulationIMMUNOCOMPROMISED INFANTSELDERLYPREGNANCYSMOKERSASTHMATICSCHRONIC DISEASE STATESATOPIC INDIVIDUALS

ADVERSE REACTIONS TO ODORS REPORTEDMay be a time dependant sensitization of the brain mediated through the olfactory nerve-Iris Bell, M.D.ABNORMAL ODOR PERCEPTION IS REPORTED-IN NONSPECIFIC BUILDING RELATED ILLNESSES MULTIPLE CHEMICAL SENSITIVITIES

AIRWAY INFLAMMATORY DISEASESALLERGIC RHINITIS SINUSITIS REACTIVE AIRWAYS DISEASEBRONCHITIS & ASTHMAALLERGIC ALVEOLITIS (HP)

ASPERGILLOSIS:AN ALLERGIC DISEASEPulmonary, sinuses, subcutaneous tissues targeted; may involve GI tract, & brainCough, wheezing, & fever; Infiltrates seen on chest x-rayAn immune response to fungi colonizing airways ;

ORGANIC DUST TOXIC SYNDROME (ODTS)Can occur after ONE heavy exposure to dust contaminated with fungi and other agents mycotoxins, endotoxins, glucans, bacteriaINHALATION FEVER FOG OF PARTICULATES OR THICK AIRBORNE DUSTnot found usually in homeSYMPTOMS: Flu-like, ache, pain, headache, lethargic feelings

HUMIDIFIER FEVERCaused by ENDOTOXINS of bacteria and fungi; MOISTURE & WARMTHFlu-like symptoms -- chills, fever, bronchospasm, chest tightness; onset 6 hours after exposure lasting 24 hoursNo treatment necessary MONDAY MORNING FLU in schools & offices

ASTHMA A lung disease-characterized by at least partially REVERSIBLE AIRWAY OBSTRUCTION, INFLAMMATION, and increased AIRWAY RESPONSIVENESS to a variety of environmental stimuli. (PREVALENCE 5-10%)

ASTHMA EXPOSURES WORK, HOME & SCHOOL EXPOSURESHOME, PERSONAL AND OFFICE CHEMICAL PRODUCTS & FOODSMICROBIAL AGENTS ON CARPETS, BEDDING, CONTAMINATED VENTILATION SYSTEMS

HYPERSENSITIVITY PNEUMONITISCaused by inhalation of fungi & the bodys IMMUNE RESPONSE TO COLONIZATION OF AIRWAYSDELAYED SENSITIZATION - months to yearsFLU-LIKE symptoms, cough, shortness of breath, tight chest, fatigue, myalgia, feverALLERGIC ALVEOLITIS

HYPERSENSITIVITY PNEUMONITIS ACUTE, CHRONIC, INDETERMINATESERUM ANTIBODIES, HIGH RESOLUTION CT LUNG SCANSDIAGNOSIS : THE CLINICAL PICTUREMUST IDENTIFY SOURCE TO PREVENT FURTHER CASES

H. PNEUMONITISMOST CASES FROM OCCUPATIONAL EXPOSURES-AGRICULTUREPET BIRDS, HUMIDIFIERS, CONTAMINATED HVAC SYSTEMS THERMOPHILIC ACTINOMYCETES ( A BACTERIA)

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INFECTIONS FROM FUNGI At risk are IMMUNE COMPROMISED individuals-HOSPITAL PATIENTSFungi can target multiple organs INFECTION & ALLERGY may coexist as in ASPERGILLOSISFungal colonization of sinuses-Most common cause of recurrent sinusitis (Mayo clinic - 1996 study)

Noninfectious INTERSTITIAL LUNG DISEASEMYCOTOXIN PRODUCING FUNGICLUSTERS SUGGEST THAT MOISURE, DIRT, AND BIOAEROSOLS ARE NOT AS HARMLESS AS PREVIOUSLY ASSUMED(Text Occ Med, Rosenstock,et al-2005)

MYCOTOXIN HEALTH EFFECTSNeurological effects (penetrates blood brain barrier) - Tremors & ConvulsionsSynergistic effects - Organic Dust Toxic Syndrome (ODTS)Cardiovascular effects - Rapid Heartbeat, Hypotension, & Others 1-3

ASPERGILLUS MYCOTOXIN HEALTH EFFECTSFLAVUSAflatoxinHepatotoxicCarcinogenic

FUMIGATUSFurnitremoransTremorigenicOCHRACEUSOchratoxin-ANephro- & Hepatotoxic

* (Aspergillus Aflatoxins is toxic to brain, liver, kidney and heart)

EFFECTS OF MYCOTOXINS ON HEALTHLOWEST OBSERVED ADVERSE EFFECT is on the IMMUNE SYSTEM Manifested as increased SUSCEPTIBILITY to infections - FREQUENT COLDS & BACTERIAL INFECTIONS (Croft, 1986; JAKAB, 1994)Almost all mycotoxins have an IMMUNOSUPPRESSIVE effect, although the exact target within the immune system may differ

MYCOTOXIN-ILLNESS ASSOCIATION DEPENDS ON:HEAVY MOISTURE CONTAMINATION of patients environmentHIGH LEVELS OF MOLD SPORES in the AIR!SYMPTOMS CONSISTENT with known effects of exposureCLINICAL EVALUATION must be objectively supportive

CONFIRM DIAGNOSIS: EXAMINE BLDGDETAILED ENVIRONMENTAL & OCCUPATIONAL HISTORY PHYSICAL EXAMINATIONSYMPTOMS & TEMPORAL EXPOSURE RELATIONSHIP DOCUMENTED IMMUNE AND ALLERGY TESTINGX-RAYS, CT SCANSRULE OUT OTHER CAUSES OF DISEASE

Unless ENVIRONMENTAL CAUSATION is consideredDIAGNOSIS may be MISSED Environmental causation LINK may be MISSEDTREATMENT may be INAPPROPRIATEOPPORTUNITY is MISSED to alert others similarly affectedILLNESS may PROGRESS & become irreversible

ENVIRONMENTAL HISTORY AXIOMS (TARCHER)Effects of environmental exposure may develop only after a long LATENCY periodMany illnesses of environmental origin become CHRONIC and thereby show NO variation with EXPOSURE PATTERNS Diagnosis of an Environmental Illness cannot always be made with certainty because many illnesses are MULTIFACTORIAL 1-2

ENVIRONMENTAL HISTORY AXIOMS (TARCHER)Vague NEUROBEHAVIORAL symptoms in children & adults may be the norm in some environmentally induced illnesses. This is a CLUE to search for an environmental causeThe SENSITIVITY OF THE BRAIN to toxic substances may provide an early barometer of their adverse effects 2-2

BUILDING WALKTHROUGHWhen WIDESPREAD ILLNESS is reportedIf LITIGATION is anticipatedWhen a question of HEALTH RISK arisesWhen a DECISION to evacuate or stay is REQUIRED* OCCUPATIONAL/ENVIRONMENTAL PHYSICIAN should be CONSULTED!

ENVIRONMENTAL ASSESSMENTVISUAL INSPECTION - water damage, mold growth, odors, ventilation systemBULK/SURFACE SAMPLING - may be required?AIR MONITORING may be required? (NYC GUIDELINES/ACGIH)

CARBON DIOXIDEINDICATOR OF VENTILATION ADEQUACYA REASONABLE PREDICTOR OF SYMPTOMSLEVELS ABOVE 1000 PPM INDICATE PROBLEMS

NONSPECIFIC BUILDING RELATED ILLNESSATOPIC INDIVIDUALS RESPOND TO IRRITANTS AT LOWER LEVELS AND HAVE LOWER IRRITANT THRESHOLDS!WORK STRESS A FACTORNSBRI-40% VENTILATION SYSTEM ASSOCIATION!-DENMARK STUDY

THE IDENTIFICATION OF ARCHITECTURAL & ENGINEERING DEFICIENCIES BY THEMSELVES SHOULD LEAD TO REMEDIATION STRATEGIES20 CUBIC FEET OF OUTSIDE AIR PER OCCUPANT PER MINUTE (ASHRAE) RECOMMENDED

ENVIRONMENTAL DESIGN & CONTROLA REVIEW OF BUILDING SYSTEMS SUGGEST THAT THE MAJORITY OF BUILDINGS IN THE U.S. SIMPLY DO NOT MEET PROFESSIONAL DESIGN STANDARDS AND THEREFORE CONTRIBUTE TO HEALTH CONCERNS & OCCUPANT DISCOMFORT

SPACE DESIGN HEALTH RISKPLACEMENT OF AIR VENTS, FURNITURE AND PARTITIONS MAY INFLUENCE THE DISTRIBUTION OF AIR FLOW LEADING TO AIR QUALITY COMPLAINTS

HEALTH RISK OF OFFICE MATERIALSIDENTIFY POTENTIAL SOURCES OF CONCERNVOC EMISSIONS & HEALTH EFFECTSSECONDARY SINKS: CARPET, UPHOLSTERY, DRAPES

MEDICAL SURVEILLANCEREVIEW objective DATA with team MembersLEARN when, why, & how PROBLEMS beganUNDERSTAND OCCUPANTS: Who affected, what symptoms, & where affectedRISK ASSESSMENT COMMUNICATION

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MEDICAL SURVEILLANCELIMITATIONS OF DATA - communicateDECISION MADE - to occupy or vacateINTERIM CONTROLS - put in placeMONITOR EFFECTIVENESS of interim controls and remediation (IAQA)

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INTERIM CONTROLSPROPER REMOVAL of mold contaminated materialsCOVER visible mold reservoirs where ableIncrease AIR FILTRATION efficiency at HVAC systemsENHANCED CLEANING using HEPA vacuumsInstall temporary DEHUMIDIFICATIONInstall local HEPA AIR CLEANERS

HAZARD COMMUNICATIONOCCUPANT NOTIFICATION of presence of contaminantsDescription of REMEDIAL MEASURES & TIMETABLE for completionSEEK MEDICAL ADVICE if health problems existCopy of all INSPECTION RESULTS & interpretation provided to physicians

(NYC GUIDELINES)

INCREASED RISK OF -POLLUTANT EXPOSURERELATED TO ACTIVITY IN A ROOMRENOVATING BUILDINGSCHANGING CARPETSREMEDIATION usually requires proper protection and occupant removal

OCCUPANT REMOVAL (Hodgson-PUBLIC HEALTH)The presence of PHYSIOLOGIC ABNORMALITIES usually warrants REMOVAL of that individualThe presence of SYMPTOMS ALONE require further investigation. Usually may work or live in homeIf large numbers of individuals are symptomatic, one is forced to remove individuals anyways

PUBLIC HEALTH CLINICAL PRACTICE GUIDELINESDOCUMENT DISEASEDOCUMENT EXPOSUREPROVE OR DISPROVE LINKAGEINTERVENECOMMUNICATE

(M. J. Hodgson, M.D., MPH)

PRUDENT PUBLIC HEALTH PRACTICE WOULD ADVISE:Speedy cleanup of molds found indoors and treat as if they are toxin producingAnd/or removal of a heavily exposed population from exposure CDC-2002 CDC ADVISES

BIBLIOGRAPHYACOEM IAQ CONFERENCE 2000ACOEM EVIDENCE BASED STATEMENT 10/27/02Is Indoor Mold Contamination a Threat to Health? - H. M. Ammann, PhD.NYC DOH Guidelines on Assessment & Remediation of Fungi in Indoor EnvironmentFungi & Bacteria in Indoor Environment, E. Johanning, M.D. & YangState of the Science on Molds & Human Health, CDC -2002, S. Redd, M.D.Principles & Practice of Environmental Medicine A. Tarcher, M.D. Textbook of Clinical Occupational & Environmental Medicine, second edition,Rosenstock,et al,Saunders, Philadelphia,2005 Copyright, 2003

Good morning . Thanks to Scot Gelfald at hodgson Russ for putting this program together. It is quite a team effort to do this informative presentation. Thanks to all those who have helped and to those of you who are attending. The purpose of my presentation today is to present an overview of the healtheffects of mold exposures.. CLEATRING THE AIR might be a more appripriate title There is a medical controversy related to indoor air health problems.Drs dont look for it. Patients fear and exagerate its effects on them. Investigators may not find abnormalities for various reasons although complaints are common. And ventilation may be the sole problem or climate controlComplaints are generally varied but nonspecific and individuals complain that they are not able to function welll because of their discomfort. Cause is difficult to define. Although temporal relationships are importantSBS causes include prsonal care products, building materials, air pollutants, ventilation and climate control problems, VOCs, and a combination of these factors People generally feel better outdoors due to better ventilation, more oxygen and where air isnt recycled. Food odors and other indoor smells seem to bother us. Ben Franklin was probably bother by indoor air pollutionPhysicians classify building illnesses according to whether or not they ere related to specific pllutants. Exposure rlated symptoms are called environmental illnessesAnthrax and pesticide poisoning might be an example; These illnesses are diagnosed by testing the building and the patientNew tight buildings focused on chemicals. In a warm humid climate where windows cant be opened most of the time and where there is lots of rain , were bound to have mold problems