Mold Health Effects Mold Sickness Can Mold Make Me Sick Mold Illness Mold Disease Mold Risk Mold Symptoms Reaction to Mold Sensitivity

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Mold and it's Health Effects

NOTE: This web site was developed only to provide general information about mold inspections and is not intended to be a valid resource for medical advice of any kind. For proper medical advice consult a physician.


Statistics show that most people spend an average of 90 percent of their time indoors. We like to think our homes are healthy places to live and raise our families and that our offices safe to work in. But just how safe are they?

Some molds release volatile compounds into the air, produce unpleasant odors and have been associated with a variety of specific health problems. Scientists label these compounds “microbial volatile organic compounds” or “mVOCs”. Exposure to mVOCs has been associated with headaches, dizziness, and fatigue.

Molds and other fungi can adversely affect human health through three processes: 1) allergic reactions;  2) infections;  and 3) toxic poisoning. Exposure to high levels of mold in enclosed areas such as indoors is not healthy for anyone. However, the following individuals are at a higher risk than others for adverse health effects;

• infants      • children      • elderly      • immune compromised patients      • pregnant
 women      • individuals with existing respiratory conditions and allergies.

Breathing toxigenic mold spores can affect the immune system, nervous system, liver, kidneys, and blood. Some experts believe toxic mold may even be responsible for certain neurological disorders. With so much compelling evidence that overexposure to molds of any kind is unhealthy, why take chances?

Everyone is exposed to moderate levels of mold in the outdoor air. Though certain types of molds are more hazardous than others, exposure to high concentrations of any type of mold indoors can accelerate a number of aggravated conditions from mild headaches to  instant and uncontrollable vomiting.
 

How does mold affect people?

There are many reactions to mold exposure, the severity of which depends on the sensitivity of the exposed person. Allergic reactions are the most common and typically include: chronic clogged throat; wheezing and difficulty breathing; nasal and sinus congestion; burning, watery, reddened eyes or blurry vision; sore throat; dry cough; nose and throat irritation; shortness of breath; nausea; and skin irritation. A person may experience these reactions while in a moldy environment and feel perfectly fine outdoors or indoors where mold levels are not elevated. People with serious allergies to molds may have more severe reactions such as fever and shortness of breath and asthma attacks. Additionally, people with chronic lung illnesses, such as bronchitis, emphysema and other obstructive lung diseases can develop severe infections in their lungs and breathing passages.

Mold is an Asthma Trigger

Not all of the health risks that are said to be cause by molds have been substantiated. But one thing the scientific and medical communities completely agree on is that mold is an asthma trigger. Over 5,000 asthma related deaths are reported in the U.S. alone each year, (mostly children). For that reason, periodic home inspections and mold testing is prudent. All indoor mold issues should be addressed immediately. People with asthma should avoid contact with molds and limit their exposure to moldy environments. For more information on indoor asthma triggers, see Allergen Screening.

How am I exposed to indoor molds?

Mold spores are found everywhere, indoors and outdoors. In reality, we are always exposed to some level of mold. On a daily basis, we breathe in thousands of mold spores without evidence of harm. But when airborne mold spores are inhaled in high concentrations they can cause a variety of health effects.

Adverse reactions to molds are most likely to occur when we are exposed to elevated levels of airborne spores in enclosed or poorly ventilated environments such as indoors. High concentrations of airborne mold spores are commonly found in homes that are damp or have experienced some sort of water intrusion. People may also experience adverse reactions to mold through skin contact and eating.  For more information about the damaging effects of mold see Mold & Property Damage.

How much mold can make me sick?

It depends. For some people, a relatively small number of mold spores can cause reactions ranging from minor to severe. Other people may experience little to no reaction. Some people will react immediately, some over a longer period of time, and some never. There is no "one size fits all" when it comes to reactions to mold. If you are sensitive to molds, anything more than the amount naturally present in outdoor air can make you sick. The basic rule is, too much of anything is not good. If you can see or smell mold, take steps to accurately assess the severity of infestation and the airborne concentrations.

Who is at greater risk of mold exposure?

Excessive exposure to mold is not healthy for anyone inside buildings where ventilation is limited. There are, however, certain individuals who are more likely to experience severe reactions to mold, including but mot limited to:

  • infants, children, and the elderly
  • immune compromised patients
    (people with HIV infection, cancer chemotherapy, liver disease, etc.)
  • pregnant women
  • individuals with existing respiratory conditions, such as allergies, multiple chemical sensitivity, and asthma.

People with these special concerns should consult a physician if they are having health problems or suspect indoor mold growth.



Nasal Polyps
 


Fungal Infection in Nose
 


Infection Being Removed
 


Surgically Removed
Fungal Balls

What symptoms are common?

Allergic responses vary in a person's sensitivities to mold, both as to amount and type needed to cause reactions. For asthma sufferers, the most common reaction to mold is an asthma attack. In addition to causing asthmatics to suffer an attack, mold may also give asthma to people who don't have it.

Other than asthma attacks, the following symptoms from mold exposure are often reported by people who live or work in areas where high concentrations of airborne mold spores have been confirmed:

  • respiratory problems, such as wheezing and difficulty in breathing
  • nasal and sinus congestion
  • eyes-burning, watery, reddened, blurry vision, light sensitivity
  • dry, hacking cough
  • sore throat and throat tightness (closing up)
  • nose and throat irritation
  • shortness of breath
  • skin irritation and staff infections
  • central nervous system problems
    (constant headaches, memory problems, and mood changes)
  • flu-like symptoms, i.e. aches, pains and fever

If you have any of these symptoms, and they are reduced or completely gone when you leave the suspect area, chances are you have been exposed to some sort of allergen, quite possibly mold.

If you or your co-workers, school mates or family members show signs of unexplained chronic fatigue, daily headaches, persistent cold-like or flu-like symptoms, you could be suffering from exposure to volatile organic compounds (VOC) and should see a physician.
 

Are some molds more hazardous than others?

Molds are organized into three groups according to human responses:

  • Allergenic
  • Pathogenic
  • Toxigenic.

For more information on the differences between them, click here or scroll down.

There a three common misconceptions about mold.

Misconception #1:  "BLACK MOLD"
The truth is, there are thousands of kinds of molds and many of them are black. Additionally, molds tend to change colors at different stages of their growth. Some molds can be gray one day, black the next day, and green the day after that. The mold that most people are referring to when they use the term  "BLACK MOLD" is a mold called Stachybotrys, pronounced STACK-EE-BOT-TRIS.

Misconception #2:  "TOXIC MOLD"
Contrary to the widely-used term, "toxic mold", there is actually no such thing as toxic mold. Certain types of molds produce poisonous chemical compounds called mycotoxins, which are toxic, but the mold itself is not literally toxic mold. Mycotoxins are poisons that some molds produce to inhibit or prevent the growth of other organisms. Mycotoxins can be found in both living (viable) and dead (non-viable) mold spores. While non-viable mold is not a threat to building materials, both viable and non-viable mold spores can have the same allergic and toxic health effects on humans. Exposure to mycotoxins may present a greater hazard than that of allergenic or pathogenic molds.

Once mycotoxins or spores are airborne, they can rest on clothing or skin and become trapped in mucus membranes from normal breathing. They can affect humans in many different ways. Some people may have immediate reactions, and others may not notice or exhibit symptoms for several days or weeks. Mycotoxins, although unseen by the naked eye, are most often inhaled but can enter the body through the skin, mucous and eyes. Once inside the human body, mold has all the requirements it needs to colonize and spread, compromising the immune system and damaging everyday processes of the body.

Misconception #3:  "ALLERGY SHOTS PROTECT AGAINST MOLD"
A common misconception among allergists who are untrained in mold-related toxicity levels in humans, (which is technically not their area of expertise unless they have trained specifically in environmental medicine with their background in immunology), is to do general allergen testing. Most tests usually result in an 2+ or less. Because many doctors are not trained in this field, they may try to "guess" at a diagnosis. Some physicians response is to order allergy shots. However, allergy shots are virtually worthless (and could possibly be harmful) to a person who has been heavily exposed to mycotoxins since they are already in a state of toxicity. If anything, this could exacerbate the problem.

Fungi, or microorganisms related to them, may cause other health problems similar to allergic diseases. Some kinds of Aspergillus may cause several different illnesses, including both infections and allergy. These fungi may lodge in the airways or a distant part of the lung and grow until they form a compact sphere known as a "fungal ball." In people with lung damage or serious underlying illnesses, Aspergillus may grasp the opportunity to invade the lungs or the whole body.

In some individuals, exposure to these fungi can also lead to asthma or to a lung disease resembling severe inflammatory asthma called allergic bronchopulmonary aspergillosis. This latter condition, which occurs only in a minority of people with asthma, is characterized by wheezing, low-grade fever, and coughing up of brown-flecked masses or mucus plugs. Skin testing, blood tests, X-rays, and examination of the sputum for fungi can help establish the diagnosis. Corticosteroid drugs are usually effective in treating this reaction; however, immunotherapy (allergy shots) is not a reliable "one-shot-fix-all" treatment.

Why take chances?

Life is too short to not live it well. If you suspect you have a mold problem in your home or workplace, address it early. Call an AMI representative to discuss services available to you to help accurately asses mold problems and resolve them.

For more information on adverse health effects click here.

SUPPLEMENTAL INFORMATION

The most common response to mold exposure may be allergy. People who are atopic, that is, who are genetically capable of producing an allergic response, may develop symptoms of allergy when their respiratory system or skin is exposed to mold or mold products to which they have become sensitized. Sensitization can occur in atopic individuals with sufficient exposure. Allergic Reactions Allergic Reactions can range from mild, transitory responses, to severe, chronic illnesses. The Institute of Medicine (1993) estimates that one in five Americans suffers from allergic rhinitis, the single most common chronic disease experienced by humans. Additionally, about 14 % of the population suffers from allergy-related sinusitis, while 10 to 12% of Americans have allergically-related asthma. About 9% experience allergic dermatitis. A very much smaller number, less than one percent, suffer serious chronic allergic diseases such as allergic bronchopulmonary aspergillosis (ABPA) and hypersensitivity pneumonitis (Institute of Medicine, 1993). Allergic fungal sinusitis is a not uncommon illness among atopic individuals residing or working in moldy environments. There is some question whether this illness is solely allergic or has an infectious component. Molds are just one of several sources of indoor allergens, including house dust mites, cockroaches, effluvia from domestic pets (birds, rodents, dogs, cats) and microorganisms (including molds).

While there are thousands of different molds that can contaminate indoor air, purified allergens have been recovered from only a few of them. This means that atopic individuals may be exposed to molds found indoors and develop sensitization, yet not be identified as having mold allergy. Allergy tests performed by physicians involve challenge of an individual's immune system by specific mold allergens. Since the reaction is highly specific, it is possible that even closely related mold species may cause allergy, yet that allergy may not be detected through challenge with the few purified mold allergens available for allergy tests. Thus, a positive mold allergy test indicates sensitization to an antigen contained in the test allergen (and perhaps to other fungal allergens) while a negative test does not rule out mold allergy for atopic individuals.

Type 1 Allergies: Immediate type - hypersensitivity. Fungi may cause allergic rhinitis similar to that caused by pollen grains, and, after asthmatics become allergically sensitized to one or more of them, they may trigger asthma attacks. Most asthmatics have multiple allergies.

Type 3 Allergies: Delayed type hypersensitivity. In certain susceptible individuals, after prolonged, heavy exposure, fungi may cause hypersensitivity pneumonitis (allergic alveolitis), characterized by wheeze, shortness of breath, cough, chest tightness, and in some prolonged cases, pulmonary fibrosis. There has been a custom of giving each new subtype of hypersensitivity pneumonitis (HP) an evocative medical nickname, such as farmer's lung, maple bark stripper's disease, and so on. "Humidifier fever" is the most common such name associated with indoor mold proliferation, since HP is often associated with contaminated humidifiers. HP has also, however, been reported from indoor mold proliferations on structural or furnishing elements, such as walls or shower curtains. A HP patient should have strong serum precipitins specific to the fungus (or bacterium or protozoan) which is causing the reaction. Bronchioalveolar lavage or biopsy will usually show elevated numbers of eosinophil cells, showing eosinophilic immune activation.

Bronchopulmonary Mycosis: Persons who have been asthmatic for many years may progress to have their bronchial passages colonized by a fungus, usually Aspergillus fumigatus, but sometimes another organism such as Bipolaris hawaiiensis, Wangiella dermatitidis, or Pseudallescheria boydii. Constant allergic response helps to maintain the fungal colonization, and first-line therapy is often with steroids: bringing down the level of inflammation may result in elimination of the colonizing organism. Some studies have made tentative links between exacerbations of ABPA and moldy houses. Cystic fibrosis patients also may get allergic bronchopulmonary mycosis.

Allergic Mycotic Sinusitis: A colonizing infection of mucus adhering to the sinus walls. Very similar to ABPA otherwise, except that patients need not necessarily have had asthma or cystic fibrosis. To date no discrete connection with indoor mold proliferation has been shown in any individual cases, but that may be from lack of investigation. Infections From molds that grow in indoor environments is not a common occurrence, except in certain susceptible populations, such as those with immune compromise from disease or drug treatment. A number of Aspergillus species that can grow indoors are known to be pathogens. Aspergillus fumigatus (A. fumigatus) is a weak pathogen that is thought to cause infections (called aspergilloses) only in susceptible individuals. It is known to be a source of nosocomial infections, especially among immune-compromised patients. Such infections can affect the skin, the eyes, the lung, or other organs and systems. A. fumigatus is also fairly commonly implicated in ABPA and allergic fungal sinusitis. Aspergillus flavus has also been found as a source of nosocomial infections (Gravesen et al., 1994). There are other fungi that cause systemic infections, such as Coccidioides, Histoplasma, and Blastomyces. These fungi grow in soil or may be carried by bats and birds, but do not generally grow in indoor environments. Their occurrence is linked to exposure to wind-borne or animal borne contamination.

Adverse Reactions to Odor: Odors produced by molds may also adversely affect some individuals. Ability to perceive odors and respond to them is highly variable among people. Some individuals can detect extremely low concentrations of volatile compounds, while others require high levels for perception. An analogy to music may give perspective to odor response. What is beautiful music to one individual is unbearable noise to another. Some people derive enjoyment from odors of all kinds. Others may respond with headache, nasal stuffiness, nausea or even vomiting to certain odors including various perfumes, cigarette smoke, diesel exhaust or moldy odors. It is not know whether such responses are learned, or are time-dependent sensitization of portions of the brain, perhaps mediated through the olfactory sense, or whether they serve a protective function. Asthmatics may respond to odors with symptoms.

Mucous Membrane and Trigeminal Nerve Irritation: A third group of possible health effects from fungal exposure derives from the volatile compounds (VOC) produced through fungal primary or secondary metabolism, and released into indoor air. Some of these volatile compounds are produced continually as the fungus consumes its energy source during primary metabolic processes. (Primary metabolic processes are those necessary to sustain an individual organism's life, including energy extraction from foods, and the syntheses of structural and functional molecules such as proteins, nucleic acids and lipids). Depending on available oxygen, fungi may engage in aerobic or anaerobic metabolism. They may produce alcohols or aldehydes and acidic molecules. Such compounds in low but sufficient aggregate concentration can irritate the mucous membranes of the eyes and respiratory system. Just as occurs with human food consumption, the nature of the food source on which a fungus grows may result in particularly pungent or unpleasant primary metabolic products. Certain fungi can release highly toxic gases from the substrate on which they grow. For instance, one fungus growing on wallpaper released the highly toxic gas arsine from arsenic containing pigments.

Fungi can also produce secondary metabolites as needed. These are not produced at all times since they require extra energy from the organism. Such secondary metabolites are the compounds that are frequently identified with typically "moldy" or "musty" smells associated with the presence of growing mold. However, compounds such as pinene and limonene that are used as solvents and cleaning agents can also have a fungal source. Depending on concentration, these compounds are considered to have a pleasant or "clean" odor by some people. Fungal volatile secondary metabolites also impart flavors and odors to food. Some of these, as in certain cheeses, are deemed desirable, while others may be associated with food spoilage. There is little information about the advantage that the production of volatile secondary metabolites imparts to the fungal organism. The production of some compounds is closely related to sporulation of the organism. "Off" tastes may be of selective advantage to the survival of the fungus, if not to the consumer.

In addition to mucous membrane irritation, fungal volatile compounds may impact the "common chemical sense" which senses pungency and responds to it. This sense is primarily associated with the trigeminal nerve (and to a lesser extent the vagus nerve). This mixed (sensory and motor) nerve responds to pungency, not odor, by initiating avoidance reactions, including breath holding, discomfort, or paresthesias, or odd sensations, such as itching, burning, and skin crawling. Changes in sensation, swelling of mucous membranes, constriction of respiratory smooth muscle, or dilation of surface blood vessels may be part of fight or flight reactions in response to trigeminal nerve stimulation. Decreased attention, disorientation, diminished reflex time, dizziness and other effects can also result from such exposures (Otto et al., 1989.

It is difficult to determine whether the level of volatile compounds produced by fungi influence the total concentration of common VOCs found indoors to any great extent. A mold-contaminated building may have a significant contribution derived from its fungal contaminants that is added to those VOCs emitted by building materials, paints, plastics and cleaners. Miller and co-workers (1988) measured a total VOC concentration approaching the levels at which Otto et al., (1989) found trigeminal nerve effects. At higher exposure levels, VOCs from any source are mucous membrane irritants, and can have an effect on the central nervous system, producing such symptoms as headache, attention deficit, inability to concentrate or dizziness.

Vascular System: Vascular System - increased vascular fragility, hemorrhage into body tissues, or from lung, e.g., aflatoxin, satratoxin, roridins

Digestive System: Digestive System - diarrhea, vomiting, intestinal hemorrhage, liver effects, i.e., necrosis, fibrosis: aflatoxin; caustic effects on mucous membranes: T-2 toxin; anorexia: vomitoxin.

Respiratory System: Respiratory System - respiratory distress, bleeding from lungs e.g., trichothecenes Nervous system, tremors, incoordination, depression, headache, e.g., tremorgens, trichothecenes.

Cutaneous System: Cutaneous System - rash, burning sensation sloughing of skin, photosensitization, e.g., trichothecenes Urinary system, nephrotoxicity, e.g. ochratoxin, citrinin.

Reproductive System: Reproductive System - infertility, changes in reproductive cycles, e.g. T-2 toxin, zearalenone.

Immune System: Immune System - changes or suppression: many mycotoxins. It should be noted that not all mold genera have been tested for toxins, nor have all species within a genus necessarily been tested. Conditions for toxin production varies with cell and diurnal and seasonal cycles and substrate on which the mold grows, and those conditions created for laboratory culture may differ from those the mold encounters in its environment. Toxicity can arise from exposure to mycotoxins via inhalation of mycotoxin-containing mold spores or through skin contact with the toxigenic molds. A number of toxigenic molds have been found during indoor air quality investigations in different parts of the world. Among the genera most frequently found in numbers exceeding levels that they reach outdoors are Aspergillus, Penicillium, Stachybotrys, and Cladosporium. Penicillium, Aspergillus and Stachybotrys toxicity, especially as it relates to indoor exposure.

Glucan Effects: Glucan Effects - Beta-1, 3-glucan is a major structural component of almost all fungal cell walls. It is a polymer of glucose similar to cellulose, but with less tendency to be found in strands. It bears considerable structural similarity to very toxic molecules known as endotoxins secreted by some bacteria, particularly some gram-negative organisms. This similarity caused an endotoxin expert, Dr. Ragnar Rylander, to investigate it as a possible candidate for the chemically irritating component found in mold conidia. It was found to activate PAMs, possibly making the lungs hyperreactive to a wide variety of foreign materials. Also, in double-blind inhalation exposure trials conducted with human volunteers, exposure correlated significantly with some non-specific respiratory symptoms. The most strongly correlating symptom, however, was headache. The contribution of glucans to indoor mold irritation is still under investigation; glucan effects may add to or synergize mycotoxin effects, or may be mistaken for mycotoxin effects in fungi where the actual amount of mycotoxin present in conidia is not sufficient to cause symptoms.

Volatile Chemical Effects: Volatile Chemical Effects - Most molds, especially those with dry conidia, produce volatile odor constituents. In a few cases, these are fruity or flowery and may be adapted to attract arthropod dispersers (e.g. insects carrying the mold conidia to new growth sites). Usually they are musty or earthy and are probably adapted to deter grazing and feeding invertebrates and vertebrates, or at least to give a distinct "not food" odor to mold colonies and their underlying nutritional substrates. A few such volatiles have been found to be directly irritating to vertebrates. Apart from experiencing such direct physiological irritation, humans and other vertebrates may be adapted to avoid such odors, and there may be a legitimate "psychological" objection to their presence in rooms. Mold growth in buildings may be accompanied by the growth of Streptomyces species, which usually have very strong earthy volatile odors. In addition, in very wet materials, copious bacteria may grow and may emit typical rotten or sour smelling odor molecules.

Invasive Pathogenesis: Invasive Pathogenesis - Of the regularly occurring indoor mold proliferation species, only a few have significant potential as opportunistic pathogens, and even these usually require a relatively strongly immuno compromised patient before they can be regarded as dangerous. Warm, moist environments, such as dirty heating ducts affected by condensation, or vanes and other apparati near heating system humidifiers, may grow Aspergillus fumigatus, the best known opportunistic mold fungus. This species also tends to occur in potted plant soils, particularly where these have not been exchanged for fresh soils (e.g., by re-potting) for several years.

Usually, a patient needs to have a relatively high degree of neutropenia (deficit in neutrophil type white blood cells, an essential component of the immune system) before he or she is seriously threatened with invasive disease by this organism. Most such patients are persons taking leukemia chemotherapy or drugs designed to prevent rejection of transplanted organs. Occasionally other predisposing factors are found, such as heavy, prolonged corticosteroid use. AIDS patients are at little risk for such diseases unless they develop lymphomas or are taking potentially neutropenia-inducing drugs such as ganciclovir. In recent years, because of the emergence of antibiotic-resistant bacteria in hospitals, some hospitals have begun to send severely neutropenic patients home. These patients are at high risk of infection by indoor infestations of A. fumigatus, A. niger, A. nidulans, A. flavus, A. terreus, Pseudallescheria boydii, Fusarium solani, F. oxysporum, F. moniliforme, F. proliferatum, and some other species. People who do not have these specific immuno-compromising conditions, however, are not at significant risk of invasive disease from any of these fungi (with the possible exception of P. boydii punctured into the dermis or the eye).

Community Effects: Community Effects - Fungally colonized materials often support a large population of arthropods, usually fungivorous (fungus-eating) mites, but also other arthropods such as booklice, millipedes and beetles (a recent sticky tape sample sent to this author from the wall of a moldy house contained a lawn of Cladosporium which was being grazed on by the drugstore beetle, Stegobium panacaea. The insect's faecal deposits consisted entirely of mold conidia). The growth of the house dust mite, Dermatophagoides pteronyssimus, in carpets,mattresses and dust accumulations may be stimulated by growth of xerotolerant (drought-tolerant) aspergilli such as A. glaucus on human skin scale litter and other dry household organic particulates. Arthropod body parts and faeces may be highly allergenic, and house dust mite in particular is well known to be highly irritating to most asthmatic children.

Medical Evaluation: Medical Evaluation - Individuals with persistent health problems that appear to be related to fungi or other bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Infants (less than 12 months old) who are experiencing non-traumatic nosebleeds or are residing in dwellings with damp or moldy conditions and are experiencing breathing difficulties should receive a medical evaluation to screen for alveolar hemorrhage. Following this evaluation, infants who are suspected of having alveolar hemorrhaging should be referred to a pediatric pulmonologist. Infants diagnosed with pulmonary hemosiderosis and/or pulmonary hemorrhaging should not be returned to dwellings until remediation and air testing are completed. Clinical tests that can determine the source, place, or time of exposure to fungi or their products are not currently available. Antibodies developed by exposed persons to fungal agents can only document that exposure has occurred. Since exposure to fungi routinely occurs in both outdoor and indoor environments, this information is of limited value.

NOTE: This web site was developed only to provide general information about mold inspections and is not intended to be a valid resource for medical advice of any kind. For proper medical advice contact a physician.

 

MORE ON MOLD & HEALTH EFFECTS


The following excerpts are taken from the New York City Department of Health and Mental Hygiene web site. To visit their web site for even more information, click this link: http://www.ci.nyc.ny.us/html/doh/html/epi/moldrpt1.html


1.1 Health Effects

Inhalation of fungal spores, fragments (parts), or metabolites (e.g., mycotoxins and volatile organic compounds) from a wide variety of fungi may lead to or exacerbate immunologic (allergic) reactions, cause toxic effects, or cause infections.11, 12, 24

There are only a limited number of documented cases of health problems from indoor exposure to fungi. The intensity of exposure and health effects seen in studies of fungal exposure in the indoor environment was typically much less severe than those that were experienced by agricultural workers but were of a long-term duration.5-10, 12, 14, 16-20, 25-27 Illnesses can result from both high level, short-term exposures and lower level, long-term exposures. The most common symptoms reported from exposures in indoor environments are runny nose, eye irritation, cough, congestion, aggravation of asthma, headache, and fatigue.11, 12, 16-20

The presence of fungi on building materials as identified by a visual assessment or by bulk/surface sampling results does not necessitate that people will be exposed or exhibit health effects. In order for humans to be exposed indoors, fungal spores, fragments, or metabolites must be released into the air and inhaled, physically contacted (dermal exposure), or ingested. Whether or not symptoms develop in people exposed to fungi depends on the nature of the fungal material (e.g., allergenic, toxic, or infectious), the amount of exposure, and the susceptibility of exposed persons. Susceptibility varies with the genetic predisposition (e.g., allergic reactions do not always occur in all individuals), age, state of health, and concurrent exposures. For these reasons, and because measurements of exposure are not standardized and biological markers of exposure to fungi are largely unknown, it is not possible to determine "safe" or "unsafe" levels of exposure for people in general.

1.1.1 Immunological Effects

Immunological reactions include asthma, HP, and allergic rhinitis. Contact with fungi may also lead to dermatitis. It is thought that these conditions are caused by an immune response to fungal agents. The most common symptoms associated with allergic reactions are runny nose, eye irritation, cough, congestion, and aggravation of asthma.11, 12 HP may occur after repeated exposures to an allergen and can result in permanent lung damage. HP has typically been associated with repeated heavy exposures in agricultural settings but has also been reported in office settings.25, 26, 27 Exposure to fungi through renovation work may also lead to initiation or exacerbation of allergic or respiratory symptoms.

1.1.2 Toxic Effects

A wide variety of symptoms have been attributed to the toxic effects of fungi. Symptoms, such as fatigue, nausea, and headaches, and respiratory and eye irritation have been reported. Some of the symptoms related to fungal exposure are non-specific, such as discomfort, inability to concentrate, and fatigue.11, 12, 16-20 Severe illnesses such as ODTS and pulmonary hemosiderosis have also been attributed to fungal exposures.5-10, 21, 22

ODTS describes the abrupt onset of fever, flu-like symptoms, and respiratory symptoms in the hours following a single, heavy exposure to dust containing organic material including fungi. It differs from HP in that it is not an immune-mediated disease and does not require repeated exposures to the same causative agent. ODTS may be caused by a variety of biological agents including common species of fungi (e.g., species of Aspergillus and Penicillium). ODTS has been documented in farm workers handling contaminated material but is also of concern to workers performing renovation work on building materials contaminated with fungi.5-10

Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, fungal contaminants and other bioaerosols, and water-damaged homes), and currently its association with SC is unproven.21, 22, 23

1.1.3 Infectious Disease

Only a small group of fungi have been associated with infectious disease. Aspergillosis is an infectious disease that can occur in immunosuppressed persons. Health effects in this population can be severe. Several species of Aspergillus are known to cause aspergillosis. The most common is Aspergillus fumigatus. Exposure to this common mold, even to high concentrations, is unlikely to cause infection in a healthy person.11, 24

Exposure to fungi associated with bird and bat droppings (e.g., Histoplasma capsulatum and Cryptococcus neoformans) can lead to health effects, usually transient flu-like illnesses, in healthy individuals. Severe health effects are primarily encountered in immunocompromised persons.24, 28, 29

1.2 Medical Evaluation

Individuals with persistent health problems that appear to be related to fungi or other bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Infants (less than 12 months old) who are experiencing non-traumatic nosebleeds or are residing in dwellings with damp or moldy conditions and are experiencing breathing difficulties should receive a medical evaluation to screen for alveolar hemorrhage. Following this evaluation, infants who are suspected of having alveolar hemorrhaging should be referred to a pediatric pulmonologist. Infants diagnosed with pulmonary hemosiderosis and/or pulmonary hemorrhaging should not be returned to dwellings until remediation and air testing are completed.

Clinical tests that can determine the source, place, or time of exposure to fungi or their products are not currently available. Antibodies developed by exposed persons to fungal agents can only document that exposure has occurred. Since exposure to fungi routinely occurs in both outdoor and indoor environments this information is of limited value.

1.3 Medical Relocation

Infants (less than 12 months old), persons recovering from recent surgery, or people with immune suppression, asthma, hypersensitivity pneumonitis, severe allergies, sinusitis, or other chronic inflammatory lung diseases may be at greater risk for developing health problems associated with certain fungi. Such persons should be removed from the affected area during remediation (see Section 3, Remediation). Persons diagnosed with fungal related diseases should not be returned to the affected areas until remediation and air testing are completed.

Except in cases of widespread fungal contamination that are linked to illnesses throughout a building, a building-wide evacuation is not indicated. A trained occupational/environmental health practitioner should base decisions about medical removals in the occupational setting on the results of a clinical assessment.


MORE ON THE 3 MOLD GROUPS:
Molds are organized into three groups according to human responses: Allergenic, Pathogenic and Toxigenic.


Allergenic Molds
Allergenic molds are most likely to affect those who are already allergic or asthmatic. The human system responses to allergenic molds tend to be relatively mild, depending on individual sensitivities, typically producing scratchy throats, eye and nose irritations and rashes.

Along with pollens from trees, grasses, and weeds, molds are an important cause of seasonal allergic rhinitis. People allergic to molds may have symptoms from spring to late fall. The mold season often peaks from July to late summer. Unlike pollens, molds may persist after the first killing frost. Some can grow at subfreezing temperatures, but most become dormant. Snow cover lowers the outdoor mold count dramatically but does not kill molds. After the spring thaw, molds thrive on the vegetation that has been killed by the winter cold.

In the warmest areas of the United States, however, molds thrive all year and can cause year-round (perennial) allergic problems. In addition, molds growing indoors can cause perennial allergic rhinitis even in the coldest climates. When inhaled, microscopic fungal spores. Sometimes, fragments of fungi may cause allergic rhinitis. Because they are so small, mold spores may evade the protective mechanisms of the nose and upper respiratory tract to reach the lungs.

In a small number of people, symptoms of mold allergy may be brought on or worsened by eating certain foods, such as cheeses processed with fungi. Occasionally, mushrooms, dried fruits, and foods containing yeast, soy sauce, or vinegar will produce allergic symptoms. There is no known relationship, however, between a respiratory allergy to the mold Penicillium and an allergy to the drug penicillin, made from the mold.

Which molds are allergenic?
Like pollens, mold spores are important airborne allergens only if they are abundant, easily carried by air currents, and allergenic in their chemical makeup. Found almost everywhere, mold spores in some areas are so numerous they often outnumber the pollens in the air. Fortunately, however, only a few dozen different types are significant allergens.

In general, Alternaria and Cladosporium (Hormodendrum) are the molds most commonly found both indoors and outdoors throughout the United States. Aspergillus, Penicillium, Helminthosporium, Epicoccum, Fusarium, Mucor, Rhizopus, and Aureobasidium (Pullularia) are also common.

Mold counts
Similar to pollen counts, mold counts may suggest the types and relative quantities of fungi present at a certain time and place. For several reasons, however, these counts probably cannot be used as a constant guide for daily activities. One reason is that the number and types of spores actually present in the mold count may have changed considerably in 24 hours, because weather and spore dispersal are directly related. Many of the common allergenic molds are of the dry spore type--they release their spores during dry, windy weather. Other fungi need high humidity, fog, or dew to release their spores. Although rain washes many larger spores out of the air, it also causes some smaller spores to be shot into the air.

In addition to the effect of day-to-day weather changes on mold counts, spore populations may also differ between day and night. Day favors dispersal by dry spore types and night favors wet spore types.


Pathogenic Molds
Pathogenic molds usually produce some type of infection. They can cause serious health effects in persons with suppressed immune systems. Healthy people can usually resist infection by these organisms regardless of dose. In some cases, high exposure may cause hypersensitivity pneumonitis (an acute response to exposure to an organism).

Pathogenic molds usually produce some type of infection. The word pathogenic literally means, "capable of causing disease". A normal, healthy individual can probably resist infection by these organisms regardless of dose. However, pathogenic molds can cause serious health effects in persons with suppressed, underdeveloped, or compromised immune systems. In some cases, high exposure may cause hypersensitivity pneumonitis (an acute response to exposure to an organism). People with compromised immune systems would be, infants and small children whose immune systems are not fully developed, elderly people whose immune systems are essentially worn out, and anyone exposed to AIDS, chemotherapy, pneumonia, bronchitis, and other respiratory infections.

Bipolaris Species
The U.S. Government's Occupational Safety and Health Administration [OSHA] lists the following as the health effects of Bipolaris mold: Allergen, Irritant, Hypersensitivity pneumonitis, Dermatitis.

Bipolaris australiensis showing sympodial development of pale brown, fusiform to ellipsoidal, pseudoseptate, poroconidia on a geniculate or zig-zag rachis.

Colonies are moderately fast growing, effuse, grey to blackish brown, suede-like to floccose with a black reverse. Microscopic morphology shows sympodial development of pale brown pigmented, pseudoseptate conidia on a geniculate or zig-zag rachis. Conidia are produced through pores in the conidiophore wall (poroconidia) and are straight, fusiform to ellipsoidal, rounded at both ends, smooth to finely roughened and germinating only from the ends (bipolar).

Description and Natural Habitats
Bipolaris is a dematiaceous, filamentous fungus. It is cosmopolitan in nature and is isolated from plant debris and soil. The pathogenic species have known teleomorphic states in the genus Cochliobolus and produce ascospores.

Species
The genus Bipolaris contains several species. Among these, three well-known pathogenic species are Bipolaris spicifera, Bipolaris australiensis, and Bipolaris hawaiiensis. The genus Bipolaris contains about 45 species which are mostly subtropical and tropical plant parasites. However, several species notably B. australiensis, B. hawaiiensis and B. spicifera, are well documented human pathogens. Clinical manifestations include mycotic keratitis, subcutaneous phaeohyphomycosis, sinusitis, peritonitis in patients on continuous ambulatory peritoneal dialysis (CAPD), and cerebral and disseminated infections.

Pathogenicity and Clinical Significance
Bipolaris is one of the causative agents of phaeohyphomycosis. The clinical spectrum is diverse, including allergic and chronic invasive sinusitis, keratitis, endophthalmitis, endocarditis, endarteritis, osteomyelitis, meningoencephalitis, peritonitis, otitis media (in agricultural field workers),and fungemia as well as cutaneous and pulmonary infections and allergic bronchopulmonary disease. Bipolaris can infect both immunocompetent and immunocompromised host.

As well as being isolated as saprophytes on plants, Bipolaris may be pathogenic to certain plant species, particularly to Graminiae and also to animals, such as the dog. It may cause nasal mycotic granuloma in the cattle. Bipolaris may also be isolated as a laboratory contaminant.

Macroscopic Features
Bipolaris colonies grow rapidly, reaching a diameter of 3 to 9 cm following incubation at 25°C for 7 days on potato dextrose agar. The colony becomes mature within 5 days. The texture is velvety to woolly. The surface of the colony is initially white to grayish brown and becomes olive green to black with a raised grayish periphery as it matures. The reverse is also darkly pigmented and olive to black in color.

Microscopic Features
The hyphae are septate and brown. Conidiophores (4.5-6 µm wide) are brown, simple or branched, geniculate and sympodial, bending at the points where each conidium arises from. This property leads to the zigzag appearance of the conidiophore. The conidia, which are also called poroconidia, are 3- to 6-celled, fusoid to cylindrical in shape, light to dark brown in color and have sympodial geniculate growth pattern. The poroconidium (30-35 µm x 11-13.5 µm) is distoseptate and has a scarcely protuberant, darkly pigmented hilum. This basal scar indicates the point of attachment to the conidiophore. From the terminal cell of the conidium, germ tubes may develop and elongate in the direction of longitudinal axis of the conidium.

Teleomorph production of Bipolaris is heterothallic. The perithecium is black in color, and round to ellipsoidal in shape. The ascospores are flagelliform or filiform, hyaline in nature and are found in clavate-shaped or cylindrical asci. Each ascus contains eight ascospores.

Susceptibility
In vitro susceptibility testing procedures have not been standardized for dematiaceous fungi yet. Very limited data are available on susceptibility of Bipolaris. These data suggest that itraconazole MICs are variable and voriconazole MICs are considerably low.

Amphotericin B and ketoconazole are used in treatment of Bipolaris infections. Surgical debridement may be indicated in some cases, such as sinusitis.


Toxigenic Molds
Mycotoxins can cause serious health effects in almost anybody. These agents have toxic effects ranging from short-term irritation to immunosuppression and possibly cancer. Therefore, when toxigenic molds are found, further evaluation is recommended.

"Black Mold" is a term commonly used to describe molds that are black and slimy. It is also often used in reference to toxic mold; molds that are know to present health risks to humans and animals by producing Mycotoxins (poisons). Mycotoxins are fungal metabolites that have been identified as toxic agents.

It should be noted, however, that not all black mold is toxic and that not all toxic mold is black. In fact, there are over 400,000 different types of mold and many of them are black in color of which only a portion have been identified. Black mold and/or toxic mold are terms often used in reference to Stachybotrys, (stack-ee-bot-ris) aka: Stachybotrys chartarum, aka: Stachybotrys atra.

Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium, Trichoderma, and Memnoniella) in addition to Stachybotrys can produce potent mycotoxins, some of which are identical to compounds produced by Stachybotrys. For this reason, Stachybotrys cannot be treated as uniquely toxic in indoor environments.

OVERVIEW:
Virtually everyone has some type of mold or another somewhere in their home. Although not all types are toxic, it is sometimes difficult to distinguish types without lab testing. Black molds can develop from water seepage, and while toxic mold is less common than other mold species, it is not rare. For that reason, it is imperative to treat and remove all molds as if they are potentially harmful. Regardless of the type of mold found, a home containing mold is essentially not a healthy home.

The notoriety of Stachybotrys leads some to believe that is the only “toxic mold”. That is not true. A number of toxigenic molds have been found during indoor air quality investigations in different parts of the world. Among the genera most frequently found in numbers exceeding levels that they reach outdoors are Aspergillus, Penicillium, Stachybotrys, and Cladosporium (Burge, 1986; Smith et al., 1992; Hirsh and Sosman, 1976; Verhoeff et al., 1992; Miller et al., 1988; Gravesen et al., 1999). Penicillium, Aspergillus and Stachybotrys toxicity, especially as it relates to indoor exposures, are discussed briefly in the paragraphs that follow.

PENICILLIUM:
Penicillium species have been shown to be fairly common indoors, even in clean environments, but can be problematic when indoor spore levels are higher than outdoors (Burge, 1986; Miller et al., 1988; Flannigan and Miller, 1994). Spores have the highest concentrations of mycotoxins, although the vegetative portion of the mold, the mycelium, can also contain the poison. The viability of spores is not essential to toxicity. In other words, a dead spore can still be a source of toxin.

ASPERGILLUS:
Aspergillus species are also fairly prevalent in problem buildings. This genus contains several toxigenic species, among which the most important are, A. parasiticus, A. flavus, and A. fumigatus. Aflatoxins produced by the first two species are among the most extensively studied mycotoxins. They are among the most toxic substances known, being acutely toxic to the liver, brain, kidneys and heart, and with chronic exposure, potent carcinogens of the liver. They are also teratogenic (Smith and Moss, 1985; Burge, 1986). Symptoms of acute aflatoxicosis are fever, vomiting, coma and convulsions (Smith and Moss, 1985). A. flavus is found indoors in tropical and subtropical regions, and occasionally in specific environments such as flowerpots. A. fumigatus has been found in many indoor samples. A more common aspergillus species found in wet buildings is A. versicolor, where it has been found growing on wallpaper, wooden floors, fibreboard and other building material. A. versicolor does not produce aflatoxins, but does produce a less potent toxin, sterigmatocystin, an aflatoxin precursor (Gravesen et al., 1994). While symptoms of aflatoxin exposure through ingestion are well described, symptoms of exposure such as might occur in most moderately contaminated buildings are not known, but are undoubtedly less severe due to reduced exposure. However, the potent toxicity of these agents advise that prudent prevention of exposures are warranted when levels of aspergilli indoors exceed outdoor levels by any significant amount. A. fumigatus has been found in many indoor samples. This mold is more often associated with the infectious disease aspergillosis, but this species does produce poisons for which only crude toxicity tests have been done (Betina, 1989). Recent work has found a number of tremorgenic toxins in the conidia of this species (Land et al., 1994). A. ochraceus produces ochratoxins (also produced by some penicillia as mentioned above). Ochratoxins damage the kidney and are carcinogenic (Smith and Moss, 1985).

STACHYBOTRYS:
Stachybotrys chartarum (atra) has been much discussed in the popular press and has been the subject of a number of building related illness investigations. It is a mold that is not readily measured from air samples because its spores, when wet, are sticky and not easily aerosolized. Because it does not compete well with other molds or bacteria, it is easily overgrown in a sample, especially since it does not grow well on standard media (Jarvis, 1990). Its inability to compete may also result in its being killed off by other organisms in the sample mixture. Thus, even if it is physically captured, it will not be viable and will not be identified in a cultured sample media, even though it is present in the environment and those who breathe it can have toxic exposures. For that reason, it is prudent to take a surface sample, such as tape or bulk, whenever evidence of black mold is found. This organism has a high moisture requirement, so it grows vigorously where moisture has accumulated from roof or wall leaks, or chronically wet areas from plumbing leaks. It is often hidden within the building envelope and inside wall cavities. When Stachybotrys is found in an air sample, it should be searched out in walls or other hidden spaces, where it is likely to be growing in abundance. This mold has a very low nitrogen requirement and can grow on wet hay and straw, paper, wallpaper, ceiling tiles, carpets, insulation material (especially cellulose-based insulation).

This information was quoted from an article called “Is Indoor Mold Contamination a Threat to Health?” by Harriet M. Ammann, Ph.D., D.A.B.T. - Senior Toxicologist at Washington State Department of Health, Olympia, Washington.

For a full copy of her report in PDF format CLICK HERE

For a full copy of her report in Microsoft Word format CLICK HERE


TIPS
1. Know what you are dealing with.
If you were told you have an animal in your house, your first question would be, “What kind of animal?” Based on the answer, you will know the best way to “suit up” for the encounter. If you know you have a kitty-cat, you may need a pair of gloves to keep from getting scratched. If you know you have a lion, you might want a whip, a chair, and a pistol just in case. Same with mold. If you are going to clean up some common allergenic molds you will need a cheap dust mask and a pair of rubber gloves. If you are going to clean up toxic mold, you will need an expensive respirator and other protective gear. Perhaps you will want to set up a containment area to keep toxic mold spores from contaminating other areas of your home. Taping off vents and duct work can help prevent the spread of toxic spores into the HVAC system as well.

2. Verify the extent of the problem.
Many of the indoor mold problems you will encounter are the direct result of water intrusion, i.e. improper drainage and irrigation, plumbing leaks, rain and condensation issues. After discovering the root of the problem and correcting it, you may be able to clean the area with bleach depending on the scope of the contamination. In the event you choose to do the clean up yourself, it is important to understand that bleach is only good for cleaning mold off of a surface. It should not be used for cleaning mold that is deeply embedded. Bleach dries too quickly to penetrate deep enough into wood or drywall to reach embedded mold. Therefore, it does not always reach mold that is embedded beyond the surface. For that reason, after or instead of cleaning with bleach, use a mildewcide (not a fungicide) disinfectant cleaner to penetrate deep into contaminated construction materials to kill embedded mold. After this you must take care to thoroughly dry the cleaned area. If there is any trace of mold left behind, it is only a matter of time before you will be repeating the entire process. One way to be sure your clean up is effective is to have the cleaned materials re-tested by your inspector.

For more information on cleaning mold CLICK HERE.

3. Hiring a Contractor
If you choose to have a contractor clean up the contamination, there are a couple of important matters for you to consider:

a) Only hire experience Mold Remediation Contractors. There are many fine and well established remodeling companies around who do great remodeling work but are not well experienced in mold remediation. Remodeling contractors who are not remediation specialist can make a bad situation absolutely horrible with their lack of mold experience.

b) Insist on references of customers who's jobs are at least one year old. A mold clean up job can look really great right after its finished. But if it isn't done correctly the problem can come back much worse than before within six months to a year.

c) Never allow your contractor to conduct his own post-remediation clearance testing.


Notes and References
1. Bata A, Harrach B, Kalman U, Kis-tamas A, Lasztity R. Macrocyclic Trichothecene Toxins Produced by Stachybotrys atra Strains Isolated in Middle Europe. Applied and Environmental Microbiology 1985; 49:678-81.


2. Jarvis B, "Mycotoxins and Indoor Air Quality," Biological Contaminants in Indoor Environments, ASTM STP 1071, Morey P, Feely Sr. J, Otten J, Editors, American Society for Testing and Materials, Philadelphia, 1990.


3. Yang C, Johanning E, "Airborne Fungi and Mycotoxins," Manual of Environmental Microbiology, Hurst C, Editor in Chief, ASM Press, Washington, D.C., 1996


4. Jarvis B, Mazzola E. Macrocyclic and Other Novel Trichothecenes: Their Structure, Synthesis, and Biological Significance. Acc. Chem. Res. 1982; 15:388-95.


5. Von Essen S, Robbins R, Thompson A, Rennard S. Organic Dust Toxic Syndrome: An Acute Febrile Reaction to Organic Dust Exposure Distinct from Hypersensitivity Pneumonitis. Clinical Toxicology 1990; 28(4):389-420.


6. Richerson H. Unifying Concepts Underlying the Effects of Organic Dust Exposures. American Journal of Industrial Medicine 1990; 17:139-42.


7. Malmberg P, Rask-Andersen A, Lundholm M, Palmgren U. Can Spores from Molds and Actinomycetes Cause an Organic Dust Toxic Syndrome Reaction?. American Journal of Industrial Medicine 1990; 17:109-10.


8. Malmberg P. Health Effects of Organic Dust Exposure in Dairy Farmers. American Journal of Industrial Medicine 1990; 17:7-15.


9. Yoshida K, Masayuki A, Shukuro A. Acute Pulmonary Edema in a Storehouse of Moldy Oranges: A Severe Case of the Organic Dust Toxic Syndrome. Archives of Environmental Health 1989; 44(6): 382-84.


10. Lecours R, Laviolette M, Cormier Y. Bronchoalveolar Lavage in Pulmonary Mycotoxicosis. Thorax 1986; 41:924-6.


11. Levetin E. "Fungi," Bioaerosols, Burge H, Editor, CRC Press, Boca Raton, Florida, 1995.


12. Husman T. Health Effects of Indoor-air Microorganisms. Scand J Work Environ Health 1996; 22:5-13.


13. Miller J D. Fungi and Mycotoxins in Grain: Implications for Stored Product Research. J Stored Prod Res 1995; 31(1):1-16.


14. Cookingham C, Solomon W. "Bioaerosol-Induced Hypersensitivity Diseases," Bioaerosols, Burge H, Editor, CRC Press, Boca Raton, Florida, 1995.


15. Rautiala S, Reponen T, Nevalainen A, Husman T, Kalliokoski P. Control of Exposure to Airborne Viable Microorganisms During Remediation of Moldy Buildings; Report of Three Case Studies. American Industrial Hygiene Association Journal 1998; 59:455-60.


16. Dales R, Zwanenburg H, Burnett R, Franklin C. Respiratory Health Effects of Home Dampness and Molds among Canadian Children. American Journal of Epidemiology 1991; 134(2): 196-203.


17. Hodgson M, Morey P, Leung W, Morrow L, Miller J D, Jarvis B, Robbins H, Halsey J, Storey E. Building-Associated Pulmonary Disease from Exposure to Stachybotrys chartarum and Aspergillus versicolor. Journal of Occupational and Environmental Medicine 1998; 40(3)241-9.


18. Croft W, Jarvis B, Yatawara C. Airborne Outbreak of Trichothecene Toxicosis. Atmospheric Environment 1986; 20(3)549-52.


19. DeKoster J, Thorne P. Bioaerosol Concentrations in Noncomplaint, Complaint, and Intervention Homes in the Midwest. American Industrial Hygiene Association Journal 1995; 56:573-80.


20. Johanning E, Biagini R, Hull D, Morey P, Jarvis B, Landbergis P. Health and Immunological Study Following Exposure to Toxigenic Fungi (Stachybotrys chartarum) in a Water-Damaged Office Environment. Int Arch Occup Environ Health 1996; 68:207-18.


21. Montana E, Etzel R, Allan T, Horgan T, Dearborn D. Environmental Risk Factor Associated with Pediatric Idiopathic Pulmonary Hemorrhage and Hemosiderosis in a Cleveland Community. Pediatrics 1997; 99(1)


22. Etzel R, Montana E, Sorenson W G, Kullman G, Allan T, Dearborn D. Acute Pulmonary Hemorrhage in Infants Associated with Exposure to Stachybotrys atra and Other Fungi. Ach Pediatr Adolesc Med 1998; 152:757-62.


23. CDC. Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants --- Cleveland, Ohio, 1993 - 1996. MMWR 2000; 49(9): 180-4.


24. Burge H, Otten J. "Fungi," Bioaerosols Assessment and Control, Macher J, Editor, American Conference of Industrial Hygienists, Cincinnati, Ohio, 1999.


25. do Pico G. Hazardous Exposure and Lung Disease Among Farm Workers. Clinics in Chest Medicine 1992; 13(2):311-28.


26. Hodgson M, Morey P, Attfield M, Sorenson W, Fink J, Rhodes W, Visvesvara G. Pulmonary Disease Associated with Cafeteria Flooding. Archives of Environmental Health 1985; 40(2):96-101.


27. Weltermann B, Hodgson M, Storey E, DeGraff, Jr. A, Bracker A, Groseclose S, Cole S, Cartter M, Phillips D. Hypersensitivity Pneumonitis: A Sentinel Event Investigation in a Wet Building. American Journal of Industrial Medicine 1998; 34:499-505.


28. Band J. "Histoplasmosis," Occupational Respiratory Diseases, Merchant J, Editor, U.S. Department of Health and Human Services, Washington D.C., 1986.


29. Bertolini R. "Histoplasmosis A Summary of the Occupational Health Concern," Canadian Centre for Occupational Health and Safety. Hamilton, Ontario, Canada, 1988.


30. Yang C. P&K Microbiology Services, Inc. Microscopic Examination of Sticky Tape or Bulk Samples for the Evaluation and Identification of Fungi. Cherry Hill, New Jersey.


31. American Society of Heating, Refrigerating and Air-Conditioning Engineers, Inc. Thermal Environmental Conditions for Human Occupancy - ASHRAE Standard (ANSI/ASHRAE 55-1992). Atlanta, Georgia, 1992.

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