Mold: Why has it become more of a concern? What does exposure mean to health? What is the role of environmental change in patient management?

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Morgan Briggs
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Presented at the: New England College of Occupational and Environmental Medicine 2015 conference "Tips, Tools & Pearls for

1 Mold: Why has it become more of a concern? What does exposure mean to health? What is the role of environmental change in patient management? Presented at the: New England College of Occupational and Environmental Medicine 2015 conference "Tips, Tools & Pearls for the Occupational and Environmental Health Professional December 4, 2015 Paula Schenck, MPH Director Indoor Environments and Health Programs UCONN Health Division of Occupational and Environmental Medicine schenck@uchc.edu

2 Acknowledgements Oluremi A. Aliyu MD MPH Paul Bureau MS MS CIH Marc Croteau MD MPH Robert DeBernardo MD MBA MPH Michael Erdil MD FACOEM Robert J. Fitzpatrick DO MPH Eileen Storey MD MPH William A. Turner MS PE LEED AP

3 Learning Objectives In patient management, the health provider will be able to: 1) Make an informed decision on the need to address environment based on current information on health effects and exposure to mold and moisture 2) Recognize the threat to respiratory health from mold/moisture indoors after severe wet weather 2) Access resources available to patients on how to evaluate and reduce moisture and mold in homes and other environments

4 Does mold exposure. 41e b4c8010f1546/49186_medium.jpg

5 Mean illness?????

6 UCONN Occupational and environmental medicine clinic Case 1: Female patient 43 Initial presentation late February, 2011 asthma, breast cancer (completed chemotherapy~6 months ago ); symptoms- dyspnea, increasing need of rescue inhaler, increasing incidence of night time cough; spirometry within normal range (in compliance with maintenance meds); recently moved to grandmother s home because condo was damaged, returns to condo to empty dehumidifier, but stays only briefly because she feels her breathing is in jeopardy; and wants to move back to her condo.

HEADLINE Feb 2 2011 Storm leaves trail of snow, ice, power outages, freezing temperatures And the story begins A winter storm left a 2000 mile long trail of

7 HEADLINE Feb Storm leaves trail of snow, ice, power outages, freezing temperatures And the story begins A winter storm left a 2000 mile long trail of snow and ice from the Midwest to the Northeast and two thirds of the nation facing downed power lines, shuttered highways and thousands of airport cancellations.

8 UCONN Occupational/environmental medicine Case 1: Female patient 43 Severe weather, indoor dampness, asthma exacerbation Respiratory symptom onset coincided with snow and ice in the winter 2011 and extensive condo damage A total snowfall of 54.9 inches of snow was recorded at Bradley Airport for January 2011, breaking the 1945 record. More storms in February 2011 added to the burden. Extreme accumulation of snow on the patient s roof over several weeks led to ice dams and water leaking into the building. Patient was counseled not to return to condo until after condo problems are fixed.

9 Today s discussion Buildings and moisture Health effects and exposure to mold and moisture The role of environmental intervention in patient care Resources For healthcare providers on treating patients, and For patients on how to reduce moisture and mold in homes and other indoor environments

10 What is it about buildings and moisture? Quality of our indoor environments- Where built, how built, how maintained Special case of schools and offices Energy conservation and IAQ- tension when making choices. Climate change and severe weather

11 EXPOSURE Environmental approach goes beyond industrial hygiene to include Building Science - A term to describe : the interrelationship among environment ( site, climate, etc.); building design, construction, materials; and building systems (such as humidity control); and how these factors determine the quality of the environment that affects the health and well being of the occupants.

12 Observations about: building condition; water, stains, damage, odor; housekeeping. Ventilation: design; operation and maintenance; air movement. When there is evidence of moisture damage, the causes of moisture intrusion should be fully investigated and fixed, mold present on nonporous, easily accessible materials cleaned, and other damaged materials discarded.

13 Building assessment selected resources Recognition, Evaluation, and Control of Indoor Mold Bradley Prezant, Donald M. Weekes, and J. David Miller American Industrial Hygiene Association, 2008, IMOM ASHRAE (American Society of Heating, Refrigerating, and Air-Conditioning Engineers) Indoor Air Quality Guide: Best Practices for Design, Construction, and Commissioning ANSI/ASHRAE Standard , Criteria for Moisture-Control Design Analysis in Buildings ANSI/ASHRAE Standard ,Ventilation for Acceptable Indoor Air Quality Bioaerosols: Assessment and Control, 1999 American Conference of Governmental Industrial Hygienists

14 UCONN Occupational/environmental medicine Case 1: Female patient 43 Severe weather, indoor dampness, asthma exacerbation Detailed building assessment liquid water on the parting walls of the unit, progressing downward for two stories to the basement removal of sheetrock revealed staining on wood framing water damage evident, a mild musty odor was sensed Remediation roof addressed, sheetrock removed inside wood framing cleaned with carbon dioxide ice pellet blasting, debris from the hot air furnace and associated ductwork professionally cleaned, and exposed surfaces meticulous cleaned clearance airborne testing showed elevated levels, cleaning continued until indoor levels became acceptable and low compared to outdoors.

15 UCONN Occupational/environmental medicine Case 1: Female patient 43 Severe weather, indoor dampness, asthma exacerbation Symptom status ~2 months after resuming living at condo documented improvement over initial visit after return to rebuilt condo; no need for rescue inhaler since condo rebuilt and return; doing well. Post script: 2 cats live with patient who tests allergic to cat allergen; patient maintains that the animals hadn t been a concern to her asthma the cats were taken care of by patient s father when she lived with her grandmother.

Catastrophic Wet Weather NASA/Goddard Space Flight

aid=3251 August 2005 Katrina, cost over $108 Billion

16 Catastrophic Wet Weather NASA/Goddard Space Flight Center Scientific Visualization Studio August 2005 Katrina, cost over $108 Billion GOES View of Hurricane Sandy. php?id=79553 October 28, 2012 Sandy, cost over $65 Billion Heavy Snow in NE US 7 October

Especially with climate change the opportunity for wet weather and subsequent water/moisture indoors is increasing. Climate Change = more severe storms & rain bombs!

17 Especially with climate change the opportunity for wet weather and subsequent water/moisture indoors is increasing. Climate Change = more severe storms & rain bombs!! Water/damage higher up in buildings, and buildings affected farther from coastline and waterways. National Climate Assessment Report

18 Mold in indoor environments indicates moisture is available for biological growth. The higher the moisture content, the more severe the illnesses (Sahakian et al. 2008). Mold that grows in dust in settings of high moisture correlates with respiratory illness (Park et al. 2008). Mold may be: 1) a direct factor influencing illness; 2) an indicator of other biological agents and bioaerosols that proliferate in conditions of excessive moisture; or 3) acting on building materials to release chemicals and dusts of concern (Nevalainen and Seuri 2005).

19 Damp Indoor Spaces and Health Selected highlights: Damp indoor environments are associated with adverse respiratory health effects Sufficient evidence of an association: upper respiratory symptoms, cough, wheeze, asthma exacerbation Limited evidence of an association: dyspnea, asthma development, lower respiratory illness in healthy children Mold or other agents in damp indoor environments Sufficient evidence of an association: upper respiratory symptoms, cough, wheeze, asthma exacerbation, hypersensitivity pneumonitis in susceptible individuals Limited evidence of an association: lower respiratory illness in healthy children Immune compromised persons are at increased risk for fungal infections in these environments

World Health Organization Review 2009 WHO GUIDELINES FOR INDOOR AIR QUALITY DAMPNESS AND MOULD http://www.euro.who.int/document/e92645.pdf Executive Summary http://www.euro.who.int/document/e92645sum.

20 World Health Organization Review 2009 WHO GUIDELINES FOR INDOOR AIR QUALITY DAMPNESS AND MOULD Executive Summary DAMP AND MOULD Health risks, prevention and remedial actions WHO and the Health and Environment World Health Organization 2009 Alliance

21 Selected highlights: Updated health effects literature review and call for research Provides more discussion than previous guidances on inflammation and possible effect on immune function as well as some recent animal and tissue work exploring toxicity. Notes that mold/moisture exposure as causality for asthma is a possibility but agrees with the IOM 2004 conclusion that asthma causality is not established at this time. Limitations in exposure assessment Exposure to toxins- via inhalation in usual indoor settings is not established. Qualitative exposure assessment is associated with health effects, relationships with quantitative mold measurements are not significant. Newer techniques-for example PCR and long term sampling have limitations outside of research settings. What does this mean to the health provider? Allergy and irritant mechanisms more likely explanation than toxicity for symptoms related to mold exposure indoors Serious respiratory illness is associated with damp indoor environments so patients should address the moisture in the environment. Health providers and their patients should discuss observations of moisture and mold rather than look to mold measurements to indicate exposure.

22 Since 2009 WHO review, we have learned.. Exposures in moldy workplaces increase the risk of developing asthma (Karvala et al. 2011). Rhinosinusitis is a risk factor for developing asthma symptoms for occupants in damp settings (Park et al. 2012). Indoor fungal exposure to Aspergillus and Penicillium sp. is associated with asthma in children (Peden and Bush 2012.) Characteristics that contribute to determining what mold will grow indoors include: Climate, geography, season, location, building construction, maintenance, use, ventilation, moisture control materials, occupants. (Nevalainen et al. 2015). Intervening on mold and moisture indoors provides an opportunity to improve respiratory symptoms, and possibly prevent asthma initiation, and address a contributing factor to the disparity in respiratory disease.

Climate Change, the Indoor Environment, and Health 2011 Selected highlights: Climate change may worsen indoor environmental problems and introduce new ones.

23 Climate Change, the Indoor Environment, and Health 2011 Selected highlights: Climate change may worsen indoor environmental problems and introduce new ones. Changes to indoor environments made to mitigate climate change bring opportunities to improve public health. Altered climatic conditions..may make existing indoor environmental problems more widespread and more severe. thus increase the urgency with which prevention and interventions must be pursued. emphasis added

24 Environmental intervention in patient care Changing the environment may have a direct role in patient management. In occupational settings where addressing the environment may be difficult at best, removal from work as an alternative maybe appropriate. This decision is complex and the provider and patient will need to consider many factors.

25 Be aware of environment and events Patient management Ask about work and home environments, activities and symptom onset. What has happened that coincides with the patient s concerns? Both large events (i.e. catastrophic wet weather, construction in the building) and small (i.e. changes in the operation of the heat and air conditioning, plumbing leaks). Counsel the patient on the importance of moisture in the environment. Provide resources/ links to resources.

Resources for patients http://hurricane-weather-health.doem.uconn.

26 Resources for patients The UCONN Heath Hurricane Sandy project website, Hurricanes and Mold: The health concerns; reducing personal risk; and rebuilding with resiliency, material was developed specifically for outreach on preventing respiratory disease associated with severe weather response. Directing your patients to these materials will help them understand the scope of the risk to cleaning up mold based on scientifically sound consensus reviews of health effects and reasoned understanding of environmental assessment.

27 UCONN Center for Indoor Environments and Health (CIEH) What Steps do I Need to Take to Clean-up Safely?

29 Can my patient safely use Personal Protective Equipment? Population-Specific Recommendations for Protection From Exposure to Mold in Flooded Buildings by Specific Activity and Risk Factor- Centers for Disease Control and Prevention Emergency Preparedness and Response Worker Health and Safety OSHA Respirator Medical Evaluation Questionnaire After the Storm: A Guide for your Safety library-data/ /fema_606.pdf

EPA http://www2.epa.gov/mold Extensive mold contamination of ceiling and walls. (photo courtesy of Terry Brennan) http://www.epa.gov/mold/moldcourse/imagegallery5.

Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture Indoors. http://doem.uchc.

30 EPA Extensive mold contamination of ceiling and walls. (photo courtesy of Terry Brennan) From Storey et al. Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture Indoors. ts/pdfs/mold_guide.pdf Update on-line program will be accessible through Marc Croteau, MD, MPH Health Effects Related to Mold and Moisture in Indoor Environments

Mold and Moisture-Related Illness, Recognition and Management A Key for the Clinician s Office - Patient Documentation This process provides the clinician with sufficient information to make a

31 Mold and Moisture-Related Illness, Recognition and Management A Key for the Clinician s Office - Patient Documentation This process provides the clinician with sufficient information to make a determination as to whether the patient has a condition that is related to an environmental or occupational factor and to proceed on to develop an appropriate approach to both clinical management and environmental intervention. nt_documentation_tables_09.pdf Guidance for Clinicians on the Recognition and Management of Health Effects Related to Mold Exposure and Moisture Indoors

US EPA http://www.epa.gov/asthma/publications.

residential mold How to prevent mold growth Flood Cleanup and the Air In Your Home http://www.

pdf English, Spanish and Vietnamese versions Mold Remediation in Schools & Commercial Buildings

32 US EPA Resources for professionals and the public A Brief Guide to Mold, Moisture, and Your Home English and Spanish pdf versions Audience: homeowners and renters How to clean up residential mold How to prevent mold growth Flood Cleanup and the Air In Your Home English, Spanish and Vietnamese versions Mold Remediation in Schools & Commercial Buildings Audience: building managers and those responsible for building maintenance Reference for remediation contractors Mold Course Indoor Air and Climate Readiness eatherization.html

33 National Institute of Environmental Health Sciences resources

34 Safety Awareness for Responders to Hurricanes: Protecting Yourself While Helping Others

35 National Institute of Environmental Health Sciences NIEHS Disaster Recovery Health and Safety Essentials for Workers, Volunteers, and Homeowners June

36 Protección personal y ayuda a los demás: consideraciones de seguridad para participantes en operaciones de auxilio tras el paso de un huracán

37 UCONN Occupational/Environmental Medicine Case 2: Female patient 42 Office worker in a building with a history of water incursion Initial presentation- 2 year history of sneezing and nasal congestion primarily while at work; dizziness, fatigue, and headaches while at work resolve in 1-2 hours after leaving for the day; intermittent skin rashes on forearms and upper chest. Non-sedating antihistamines improve symptoms but she is concerned that the symptoms persist and she does not want to take a medication long term. The initial physical exam unremarkable, normal spirometry, slightly elevated ESR.

38 UCONN Occupational/Environmental Medicine Case 2: Female patient 42 Office worker in a building with a history of water incursion Office setting- upper floor of a multi-story building, recurring water incursion from windows, sliding doors, and the roof. Carpet tiles repeatedly wetted on the perimeter of the building, then cleaned and moved to other parts of the floor. Stained ceiling tiles replaced at times. Symptoms exacerbated after renovation to replace carpet and repair the water damage. Stachybotrys chartarum isolated from interior wall samples. Others from same work setting seeking care

39 UCONN Occupational/Environmental Medicine Case 2: Female patient 42 Office worker in a building with a history of water incursion Tried multiple offices on dryer floors and areas; initially, did well. Marked flare-ups at work, increasingly severe symptoms that did not resolve quickly after work; some wheezing at the end of each work day, that sometimes persisted at night and resolved only on weekends. Spirometry defect that improved with a bronchodilator, consistent with asthma. Relocated to another building, did well. Sometime later, employer asked her to move back to the building. Building owner had addressed some environmental concerns, but technical assessments fall short of concluding that all water sources have been addressed. What should the discussion of the health risks and environmental interventions focus on now? Would you recommend that this patient move back to the building?

40 Patient management and environmental intervention Be aware of environment and environmental events Address the environment to reduce risks, if possible Separate people from exposures Manage the illness Communicate risk Prevention Seek to understand the cause Improve the indoor environment Maintain buildings and HVAC/heating, ventilation and air conditioning systems Opportunity in green buildings, but newer doesn t always translate into healthier environments.

41 Landsat satellite image of Connecticut

Workshop: Hurricanes and Mold July 23, :00PM -4:30PM Savin Rock Conference Center West Haven, CT 06516

Center for Indoor Environments and Health Recovery from Catastrophic Weather: mold exposure and health-related training * Workshop: Hurricanes and Mold July 23, 2014 1:00PM -4:30PM Savin Rock Conference