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Pediatric%20Environmental%20Health

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2 episodes (1 hospitalization) for pneumonia ... Pneumonia. ABPA. rashes ... Pneumonia. Chronic Bronchitis. Cough-Equivalent Asthma. Gastroesophageal reflux. Migraine ... – PowerPoint PPT presentation

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Title: Pediatric%20Environmental%20Health


1
Pediatric Environmental Health
Health Effects of Indoor Mold Exposure
2
This 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.
3
Talk 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
4
Case 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

5
Photo courtesy Alan Woolf, MD, MPH
6
Pathogenesis of environmental toxic injury
Contaminated Environment
Biologically Effective Dose
Biological Uptake
Target Organ Contact
Absorption Distribution Metabolism Excretion
Biologic Change
Clinical Disease
Repair Threshold
7
Building-Related Medical Illness
Building-Related Medical Illness
Non-specific sick building syndrome
Specific Indoor Air Quality Problems
Allergic
Non-Allergic
8
What 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)

9
Typical Damp Environment-Related Health Complaints
  • Headache
  • Fatigue
  • Light headedness
  • Eye and nose irritation
  • Cough
  • Wheezing, exacerbation asthma
  • Skin itching and rashes

10
Risk 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?

11
Risk 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

12
Back 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

13
Biological Agents Growing on Damp Indoor Spaces
Fungi Bacteria Dust mite Cockroach
Picture courtesy John Martyny, PhD - EPA
14
Respiratory 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
15
Institute 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
16
IOM 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

17
Respirable 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
18
Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Irritant
Allergy
Infection
19
Case 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?

20
Case 14 month old with multiple respiratory
illnesses? Part 3
  • Pediatricians preliminary diagnosis asthma

21
Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Allergy
Hypersensitivity Pneumonia
Asthma
Rhinitis
ABPA
rashes
22
Allergic 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)
23
Uncommon 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
24
Hypersensitivity 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)

25
Allergy 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

26
The 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

27
Black mold in a newly constructed home
Photo courtesy Alan Woolf, MD, MPH
28
Photo courtesy Alan Woolf, MD, MPH
29
molds are everywhere
Photos courtesy Rose Goldman, MD, MPH
30
Boston Globe 06/14/03
31
Flooding from Katrina
32
Types 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
33
What about the fathers complaints of cough and
headache? What other information do you need to
know about his illness?
34
Differential diagnosis considerations of cough
headache in an adult
  • Pneumonia
  • Chronic Bronchitis
  • Cough-Equivalent Asthma
  • Gastroesophageal reflux
  • Migraine
  • Tension Headache
  • Dental abscess
  • Sinusitis

35
Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Irritant
Allergy
Infection
Immuno Compromised
36
Case 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

37
Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Irritant direct or VOC mediated
Eye, nose, throat symptoms
Cough, wheeze
38
Pathogenesis of injury from molds damp spaces
Mold Damp Spaces
Mycotoxin
Infantile pulmonary Hemorrhage?
Pneumonia
39
Examples of Mycotoxins
  • Aflatoxin
  • Cyclochloritine
  • Ethanol
  • Griseofulvin
  • Ipomeamarone
  • Luteoskyrin
  • Ochratoxin
  • Sporidesmin
  • Sterigmatocystin
  • Tetracycline

Photo courtesy Terry Brennan - EPA
40
Poisoning 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

41
STACHYBOTRYS
  • 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
42
Stachybotrys 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...

43
Pathogenesis of infection from molds
Mold Damp Spaces
Infection
Immuno Compromised
Skin nail infections
other systemic infection
ABPA
Sinusitis
pneumonia
44
Fungal Pathogens
  • Fungal Pathogens - regional, often do not grow
    indoors
  • Candida - ubiquitous
  • Cryptococcus - associated with bird droppings
  • Histoplasma - (bats) Ohio valley
  • Coccidioides - Southwestern U.S.

45
Visual 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
46
Assessment 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
47
Indoor 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
48
Examples 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.
49
Limitations 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
50
Management 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?
51
Hazard 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
52
Summary
  • 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

53
Resources Mold-Related Illness
  • Clinical Resources Occupational Environmental
    Clinics Pediatric Environmental Health
    Subspecialty Units AOEC
  • Local State Health Departments
  • ATSDR Regional EPA
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