Title: Pediatric%20Environmental%20Health
1Pediatric Environmental Health
Health Effects of Indoor Mold Exposure
2This educational module was produced by Rose
Goldman, MD, MPH and Alan Woolf, MD, MPH for The
University of Texas Health Science Center at San
Antonio (UTHSCSA) Environmental Medicine
Education Program and South Texas Environmental
Education and Research Program (STEER-San
Antonio/Laredo/Harlingen,Texas)Administrative
support was provided by the Association of
Occupational and Environmental Clinics through
funding to UTHSCSA by the Agency forToxic
Substances and Disease Registry (ATSDR), U.S.
Department of Health and Human Services.Use of
this program must include acknowledgement of the
authors,UTHSCSA and the funding support.For
information about other educational modules
contact the UTHSCSA STEER office, Mail Code
7796, 7703 Floyd Curl Drive, San Antonio,Texas
78229-3900,(210)567-7407.
3Talk Objectives
- The participant will
- Understand the pathogenesis of environment-related
health problems - Appreciate the taxonomy and regional variation of
molds - Appreciate the relationship between molds and
other microbial overgrowth in a damp space - Know how to assess the patient with health
complaints related to living in a damp space - Know how to assess the environment of a patient
with damp space-related complaints - Be able to cite aspects of mold clean-up and
prevention - Know how to access resources for further
information
Photos courtesy EPA
4Case 14 month old with multiple respiratory
illnesses? Part 1
- 2 previous episodes bronchiolitis 12 visits to
local physician - 2 episodes (1 hospitalization) for pneumonia
- Father has chronic cough of 2- months duration
and complains of headaches. No fever but some
greenish nasal discharge. - Parents think that mold in their newly built home
in this suburban community is the cause - Here is the community
5Photo courtesy Alan Woolf, MD, MPH
6Pathogenesis of environmental toxic injury
Contaminated Environment
Biologically Effective Dose
Biological Uptake
Target Organ Contact
Absorption Distribution Metabolism Excretion
Biologic Change
Clinical Disease
Repair Threshold
7Building-Related Medical Illness
Building-Related Medical Illness
Non-specific sick building syndrome
Specific Indoor Air Quality Problems
Allergic
Non-Allergic
8What are some of the Major Indoor Air Pollutants?
- Respirable particles
- Oxides of nitrogen
- Carbon monoxide
- Volatile Organic Compounds (VOCs)
- Radon and radon daughters
- Asbestos fibers
- Toxic dusts (lead)
- Environmental tobacco smoke
- Biologic Agents (eg mold, endotoxin) and indoor
allergens (mites)
9Typical Damp Environment-Related Health Complaints
- Headache
- Fatigue
- Light headedness
- Eye and nose irritation
- Cough
- Wheezing, exacerbation asthma
- Skin itching and rashes
10Risk Factors Children
- Which children are susceptible to inhaled
exposures? - Why kids versus adults?
- Where besides the home would you look for
environmental contaminants affecting children?
11Risk Factors childhood illness from poor indoor
air quality and dampness-related effects
- PHYSIOLOGY
- Closer to ground-level toxins
- Higher minute ventilation
- DEVELOPMENTAL
- Pulmonary system
- Immune system
- Genetic
- SUSCEPTIBILITY
- Prematurity?
- Frequent wheezing, prior bronchiolitis
- Chronic respiratory illness (e.g. cystic
fibrosis) - OTHER ENVIRONMENTS
- Indoor air quality problems in school, preschool
or daycare
12Back to the case
- This was a new home. There was no evidence for
- Dusty environment
- Carbon monoxide (detectors in place)
- Oxides of nitrogen
- Radon
- Water intrusion
- Asbestos
- Lead
- Parents denied any exposure to
- Environmental tobacco smoke
- Use of solvents or other VOCs
13Biological Agents Growing on Damp Indoor Spaces
Fungi Bacteria Dust mite Cockroach
Picture courtesy John Martyny, PhD - EPA
14Respiratory Illnesses Damp Environments
- Asthma, wheezing, cough and phlegm associated
with residing in damp or water-damaged homes. - Irritant related nasal, eye, throat irritation
- Dampness also associated with cockroach and mite
infestation, bacterial growth (bacterial
endotoxins), biofilms
Photo courtesy EPA
15Institute Of Medicine Damp Spaces
Sufficient Evidence - upper respiratory tract
symptoms, cough, wheeze, asthma in sensitized
person Limited evidence - dyspnea, lower tract
illness in otherwise healthy person, asthma
development
16IOM Report Damp Spaces
- Inadequate or insufficient evidence
- Airflow obstruction, COPD
- Acute idiopathic pulmonary hem. in infants
- GI tract problems
- Neuropsychiatric symptoms, fatigue
- Reproductive effects
- Rheumatologic and other immune diseases
17Respirable Particles
- About 6000 liters of air exchange per day for an
adult - Smallest particles reach alveoli
- Some particles stimulate macrophage inflammatory
response - Water soluble chemicals cause proximal
irritation, less deposition distally
From chapter 16, Clinical Pulmonary Toxicology
author Lee S. Newman, in Sullivan JB and Krieger
GRClinical Environmental Health and Toxic
18Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Irritant
Allergy
Infection
19Case 14 month old with multiple respiratory
illnesses? Part 2
- 2 previous episodes bronchiolitis 12 visits to
local MD - 2 episodes (1 hospitalization) for pneumonia
- Father has chronic cough of 2- months duration
and complains of headaches - What is in your differential diagnosis?
20Case 14 month old with multiple respiratory
illnesses? Part 3
- Pediatricians preliminary diagnosis asthma
21Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Allergy
Hypersensitivity Pneumonia
Asthma
Rhinitis
ABPA
rashes
22Allergic and Hypersensitivity Reactions
About 10 of the population has allergic
antibodies to fungal antigens, and 5 have
clinical illness Outdoor molds more abundant and
important in airway allergic disease Allergic
rhinitis (hay fever) or asthma Atopic
individuals mast cell degranulation, IgE
antibodies (immediate hypersensitivity) Indoor
common molds Penicillium, Aspergillus Outdoor
Cladosporium, Alternaria (but can also come
indoors)
23Uncommon Allergic and Hypersensitivity syndromes
Allergic bronchopulmonary aspergillosis
(ABPA)-growth of aspergillus in allergic persons,
or those with cystic fibrosis, with airway damage
from previous illnesses Allergic bronchopulmonary
mycosis Allergic Fungal Sinusitis
(AFS)-Aspergillus, Curvularia Specific criteria
for ABPA and AFS Exposure to ubiquitous
organisms-no link to specific exposures at home
or school
24Hypersensitivity Pneumonitis
- Rare, exposures (usually occupational) to very
high concentrations of fungal (or other) proteins - High levels of IgG proteins-detected in
precipitin tests or gel diffusion (BUT can have
IgG ab, no disease) - Cell-mediated and humoral immune
reactivity-delayed intense local reactions - Examples in humidifier and HVACs-thermophilic
Actinomyces (filamentous bacteria)
25Allergy Assessment
- Blood count, white cell count, eosinophils
- Nasal eosinophils
- Immune competency Ig levels, IgE
- Sweat test
- Chest x-ray
- RAST testing
- (Sensitivity testing)
- (Pulmonary function tests)
- (Provocative testing)
- () reserved for older patients
26The familys discovery
- Attic had no fan and very small soffets
- It was a rainy, wet spring following the homes
construction - The builder had used improperly cured green
plywood
27Black mold in a newly constructed home
Photo courtesy Alan Woolf, MD, MPH
28Photo courtesy Alan Woolf, MD, MPH
29molds are everywhere
Photos courtesy Rose Goldman, MD, MPH
30Boston Globe 06/14/03
31Flooding from Katrina
32Types of indoor molds commonly associated with
adverse health effects
- Alternaria most common allergen
- Aspergillus (A. fumigatus, flavus, niger) 175
species, including 16 known human pathogens
filamentous, some strains mycotoxin-producing - Penicillium 200 species, indoors, allergenic
(hypersensitivity pneumonia, allergic alveolitis,
keratitis, otomycosis, penicilliosis) - Stachybotrys atra thrives on cellulose (e.g.
sheetrock, wallpaper, paper-backed gypsum,
ceiling tiles, insulation), causes dermatitis,
rhinitis, nose bleeds, cold symptoms, malaise - Cladisporium ubiquitous, breaks down cellulose,
pectin, lignin, buoyant spores
Photos courtesy John Martyny, PhD - EPA
33What about the fathers complaints of cough and
headache? What other information do you need to
know about his illness?
34Differential diagnosis considerations of cough
headache in an adult
- Pneumonia
- Chronic Bronchitis
- Cough-Equivalent Asthma
- Gastroesophageal reflux
- Migraine
- Tension Headache
- Dental abscess
- Sinusitis
35Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Irritant
Allergy
Infection
Immuno Compromised
36Case Outcomes
- Parents relocated to grandparents home in the
next town - No further health complaints child or father
- Family successfully sued builder for remediation
- This outcome does not prove that mold caused the
health complaints - For example, airborne and dust-laden endotoxin
from bacteria,volatile organic compounds
associated with microbial overgrowth, dust mite
or cockroach antigens, or airborne particulates
might also have played causative roles
37Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Irritant direct or VOC mediated
Eye, nose, throat symptoms
Cough, wheeze
38Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Infantile pulmonary Hemorrhage?
Pneumonia
39Examples of Mycotoxins
- Aflatoxin
- Cyclochloritine
- Ethanol
- Griseofulvin
- Ipomeamarone
- Luteoskyrin
- Ochratoxin
- Sporidesmin
- Sterigmatocystin
- Tetracycline
Photo courtesy Terry Brennan - EPA
40Poisoning related to mycotoxins
- Toxigenic species do not always produce toxins
- Mycotoxins usually large, non-volatile molecules
that do not off-gas or pass through walls - Ingestion of moldy foods (e.g. aflatoxin in
grains produces hepatitis hepatocarcinoma) - Stachybotrys species produce trichothecenes
- Stachybotrys-associated infantile pulmonary
hemorrhage
41STACHYBOTRYS
- Greenish black, saprophytic, grows well on
cellulose - Produces spores in a slimy, mucilaginous mass
- Some species produce trichothecenes
- Controversy over 10 cases infantile pulmonary
hemorrhage in Cleveland, Ohio
Photo courtesy EPA
42Stachybotrys chartarum Kuhn DM, Ghannoum MA. Clin
Microbiol Rev 2003 16144-72
- Is there illness found with building associated
mycotoxins produced by Stachybotrys , or toxic
mold? - Acute pulmonary hemorrhage in infants in room
with Stachybotrys-?related - For toxicity need high exposure - What is a
toxic dose? Could it occur in a typical indoor
environments - current human studies uniformly suffer from
significant methodological flaws, making their
findings inconclusivehave not found supportive
evidence for serious illness due to Stachybotrys
exposure...
43Pathogenesis of infection from molds
Mold Damp Spaces
Infection
Immuno Compromised
Skin nail infections
other systemic infection
ABPA
Sinusitis
pneumonia
44Fungal Pathogens
- Fungal Pathogens - regional, often do not grow
indoors - Candida - ubiquitous
- Cryptococcus - associated with bird droppings
- Histoplasma - (bats) Ohio valley
- Coccidioides - Southwestern U.S.
45Visual Assessment - Environment
- Interior materials wet carpet, insulation
- Building materials wet wood, wallboard, ceiling
tiles - Furnishings damp fleecy furnishings
- Heating, Ventilation, Air Conditioning (HVAC)
condensate pans, moist dirty ductwork - Pipes, Drainage clogged drains, wet traps,
leaking water pipes, wet pipe wrappings - Ventilation blocked soffets vents, no fans
Photo courtesy Terry Brennan - EPA
Photo courtesy John Martyny, PhD - EPA
46Assessment of possible mold-related illness
- Biological assessment characterize signs and
symptoms confirmatory - testing when indicated
- Environment
- visual inspection
- air samples (spore count, CFU/m3)
Photos courtesy EPA website
47Indoor airborne fungi levels
- Indoor air levels are a reflection of outdoor
levels (estimated at 40-80 of outdoor levels)
with similar rank order species of fungi. - Concentrations of fungi in samples not exposed
directly to indoor air may not indicate
inhalation risk - Estimated that 70 of homes have some mold
growing behind walls.
Photo courtesy EPA
Bardana EJ. Immunol Allergy Clin North Am 2003
23291-309
48Examples of seasonal total mold counts in the
U.S.
Data from the National Allergy Bureau, American
Academy of Allergy, Asthma and Immunology. Pollen
and mold counts. Available at http//www.aaaai.or
g
Bardana EJ. Immunol Allergy Clin North Am 2003
23291-309 Photo courtesy Rose Goldman, M.D.
49Limitations of Testing
- Airborne spores are usually 4-100 microns
diameter - Spore counts do not necessarily predict symptoms
- Not all spores are equally pathologic
- Spore counts may fluctuate daily, seasonally
- This is not an exact science!
Photos courtesy John Martyny, PhD EPA website
50Management Prevention
Photo by Mike Ahlers, CNN
Photo FEMA, Naumann
What do you see in these pictures? What is
possibly the composition of the slime? What good
bad practices do you see in the clean-up?
51Hazard Reduction
- Environment Prevent water intrusion, all reused
materials - dried and visibly mold-free
- Clean-Up Proper PPE, Mold disinfectant
(hypochlorites) or disposal EPA recommends - hiring a professional for mold
- growths gt 10 square feet in size
- Monitoring Post-occupancy De-humidification lt
60 relative humidity
N-95 respirator
Above photo courtesy Chin Yang
3 photos courtesy Terry Brennan EPA website
52Summary
- Mold-related exposures over-diagnosed, costly,
preventable - Damp spaces cause poor health (mold only one of
many concerns) - Childrens differences size, physiology,
development, behaviors - Mechanisms of mold injury
- Irritant
- Allergy
- Infectious
- Toxic
- Common clinical issues
- Mold-related illness
- diagnosis medical management
- Safe environmental clean-up
- Prevention
53Resources Mold-Related Illness
- Clinical Resources Occupational Environmental
Clinics Pediatric Environmental Health
Subspecialty Units AOEC - Local State Health Departments
- ATSDR Regional EPA