Water damage & Fungal Remediation - Protective Equipment Regulation and Guidelines

Transcription

1 Water damage & Fungal Remediation - Protective Equipment Regulation and Guidelines Dr. med. Eckardt Johanning, M.D.,M.Sc. Fungal Research Group Foundation, Inc. & Columbia University, New York

2 Overview Introduction to topic Exposure biological agents Evidence und Controversy Personal Protective Equipment (PPE) Conclusion

3 Ebola and PPE Dallas, Texas, USA ( NYT) Frankfurt, Germany

4 The first steps. New York City in the subways School sanitizing Transport of Nures New York City Bellevue Hospital

5 Catch up: daily new rules and directives in the s

6 Hurricane Katrina 2005 Sandy 2012 Haiyan 2013 Flooding Risk Superstorm and destruction more likely: - Warming sea level rise (US East Coast 4x faster) % more rain fall - Water vapor and higher ocean temp fuel storm - Unusual path of storm - Katrina-magnitude events have been twice as frequent in warm years compared with cold years

7 And now clean it up but how?

8 Muck out Dampness and mold growth Hotel room Hawaii Peziza, Coprinus fungi

9 Sandy Cough Plagues Homeowners Cleaning Up NBC NY Nov 28, 2012 Remediation worker in Germany Superstorm Sandy Deaths, Damage And Magnitude: What We Know One Month Later Huffingtonpost 11/29/12 Fungal Research Group Foundation A living, lurking threat in Sandy-hit homes: mold AP; Feb 3, 2013

10 Review of health hazards and prevention measures for response and recovery workers and volunteers after natural disasters, flooding, and water damage: mold and dampness Eckardt Johanning, Pierre Auger, Philip, R. Morey, Chin S. Yang & Ed Olmsted Environ Health Prev Med (2014) Systematic source removal, cleaning with soap and water, and bulk removal followed by high efficiency particulate air vacuuming is recommended in most cases; use of biocides should be avoided in occupied areas. adequate respiratory, skin, and eye protection use of dust control measures appropriate personal protective equipment large-scale projects: trained remediation workers who have medical clearance

11 Review of health hazards and prevention measures for response and recovery workers and volunteers after natural disasters, flooding, and water damage: mold and dampness Eckardt Johanning, Pierre Auger, Philip, R. Morey, Chin S. Yang & Ed Olmsted Environ Health Prev Med (2014)

12 Newer Literature

13 Learning from a patient: Case study (1991) 30 y female museum worker/volunteer Clean-up moldy cardboards / paper in basement for 3 days Acute Sx Gastro-intestinal (? Gallbladder attack) Fever/chills / cold-sweats Myalgia (muscle aches) Hand rash Liver tenderness Immune function problems Anorexia Neuro-cognitive problems Fungal Research Group Foundation

14 The New Museum Case Study New York City Fungal Research Group Foundation

15 Fungal Research Group Foundation

16 Sentinel Case - 2: 11 y hispanic with Genetic Disease & Worsening Asthma The mother is right the medical expert is wrong!... Fungal Research Group Foundation

17 Fungal Research Group Foundation

18 Diagnostisches Problem Exposure Multiple Mixture - dose Non-specific symptoms Multiple disease endpoints Fungal Research Group Foundation

19 Fungal Research Group Foundation Fungal Exposure: Various agents and disease outcomes Agents: Allergens Ergosterol (1-3)-ß-D-glucan Mycotoxins microbial volatile organic compounds (MVOCs)??? Allergy + Non-allergic Dermatitis, Urticaria Rhinitis, Sinusitis Asthma Extrinsic allergic alveolitis humidifier fever Organic dust toxic syndrome Toxic irritant effects

20 Health effects of fungi rare irreversible -Mycotoxicosis -Hypersensitivity pneumonitis/odts -Asthma & Bronchitis -Allergic diseases -Dermatitis; air way infections - Irritative and non-specific symptoms frequent Fungal Research Group Foundation reversible

21 Exposure Routes Inhalation Respiratory tract: Mouth and nose Contact with skin and mucous membranes: Hand, nose and eyes Ingestion: Stomach, liver and kidney

22 PPE in Germany Persoenliche Schutzausruestungen (PSA)

23 Criteria for PPE selection PSA in Germany Respiratory Protection P2 or P3 (HEPA) Body and skin protection Gloves (rubber-, neoprene, nitrile, Polyurethane oder PVC material) Schutzanzug mindestens vom Typ 5 Eye protection Full face / googles Foot protection Water proof clothing Chemical resistant protection

24 Allergies and Toxicity Upper and lower respiratory symptoms including nasal and sinus congestion irritation sore throat, chest burning,cough wheeze chest tigthness exertional shortness of breath IOM report 2004 Damp Indoor Spaces and Health

25 Irritation Mazur LJ, Kim J, Committee on Environmental Health AAP Pediatrics 2006;118: Irritation of airways Humidifier fever Organic dust syndrome

26 Toxic encephalopathy Memory decline Headaches Ligthheaddness Insomnia Loss of coordination Poor cognitive function in children Fatigue Depression

27 Neurological and psychological effects Auger PL et al 1999: in Bioaerosols, Fungi, and Mycotoxins: Health effects, assessment, prevention and control Gordon WA et al Applied Neuropsychology 2004;11:65-74 Baldo JV et al Applied Neuropsychology 2002;9: Crago BR et Arch Environ Health 2003;58: Kilburn KH Arch Environ Health 2003;58: Shenassa ED et al Am J Public Health 2007; 97 Jedrychowski W et Polish study on 6 year old children Physiology&Behavior ;

28 Unequal human sensitivity to toxics Gordon WA, Cantor JB «The diagnosis of cognitive impairment associated with exposure to molds» Advance in Applied Microbiology 2004;55:

29 Possible mechanisms Instillation of Aflatoxin into the Olfactory Mucosa of Rodents Larsson P et al Toxicology& Science : Mycotoxins Damage to Human Neurological Cell Lines Karunasena E et al Mycopathologia : Instillation satratoxin-g (Stachybotrys chartarum) Rhinitis and Apotosis of Olfactory Sensory Neurons in the Nasal Airways of Rhesus monkeys Carey SA e al ToxicolPathol 2012;40:887

30 High-dose and repeated low-dose SG elicited a 13% and 66% reduction in OSN volume density, and a 14-fold and 24 fold increase in apoptotic cells of the OE, respectively. This model provides new insight in to the potential risk of nasal airway injury and neurotoxicity caused by exposure to water-damaged building Nasal passages of the rhesus monkey nose. Fungal Research Group Foundation

31 CONCLUSIONS: Our findings extend the 2004 conclusions of the Institute of Medicine by showing that mold levels in dust were associated with new-onset asthma in this damp indoor environment. Hydrophilic fungi and ergosterol as measures of fungal biomass may have promise as markers of risk of buildingrelated respiratory diseases in damp indoor environments. Environ Health Perspect 116:45 50 (2008). Fungal Research Group Foundation

32 Rhinosinusitis and mold as risk factors for asthma symptoms in occupants of a water-damaged building J.-H. Park, K. Kreiss, J. M. Cox-Ganser - National Institute for Occupational Safety and Health, Division of Respiratory Disease Studies, Morgantown, WV, USA The BR-rhinosinusitis symptom group had higher odds for developing BR-asthma symptoms [odds ratio (OR) = 2.2; 95% confidence interval (CI) = ] in any subsequent survey compared to those without BR-rhinosinusitis symptoms. The BR-rhinosinusitis symptom group with higher fungal exposure within the building had an OR of 7.4 (95% CI = ) for developing BR-asthma symptoms, compared to the lower fungal exposure group without BR-rhinosinusitis symptoms. Our findings suggest that rhinosinusitis associated with occupancy of waterdamaged buildings may be a sentinel for increased risk for asthma onset in such buildings. (Indoor Air 2012; 22: ) Fungal Research Group Foundation

33 Fungal Research Group Foundation

34 Others Child Pulmonary Hemorrhage Vesper SJ, Dearborn D et al Applied and Environmental Microbiology 2000 pp Immunological Johanning E et al Int Arch Occup Envron Health 1996;68: Inflammatory Rheumatic diseases Myllykangas-Luosujarvi R et al Clin Experiment Rheumatology 2002;20: Luosujarvi et al Clinical Rheumatology 2003;

35 Causal agents MVOC Microbial Volatile organic compounds Irritation and odors Endotoxins Lipopolysaccharide from membrane of Gram-negative bacteria Humidifier fever Beta-1-3-d-glucan Basic membrane stuctural polyglucosidic compound Able activate Th1 and Th2 cells which can induce a non specific immunologic response or a systemic allergic reaction Organic dust syndrome

36 Mycotoxins Secondary fungal metabolite alkaloids, cyclopeptides, and coumarins 400+ mycotoxins discovered toxic mold black mold : Aspergillus versicolor, Penicillium, Fusarium, Trichoderma, Cephalosporium, Chaetomium, Stachybotrys Documented properties in animals/humans: genotoxic, mutagenic, cytotoxic, carcinogenic, nephrotoxic, pseudoestrogenic, immuno-suppressive, protein synthesis inhibitor or other toxic properties Fungal Research Group Foundation

37 Stachybotrys chartarum Peska JJ et al Stachybotrys chartarum Tricothecene Mycotoxins, and Damp building-related Illness: New Insights Tricothecene A,B,D Atranone Hemolysins Proteinase Spirocyclic Drimanes

38 Animal and human studies with trichothecenes Beasley VB Trichothecene mycotoxicosis:pathophysiologic effects Volumes 1-2 CRC Press 1989 Immunotoxicity Hemostasis and red cell production Effects on the digestive system and energy metabolism Circulatory system Nervous system Integumentary system

39 Toxic metabolites from bacteria? Taubel M et al 2011 Indoor air;21: Peitzsch M 2012 J. Environ.Monit ;14: Streptomyces species: Gram positive bacteria potent producers of bioactive metabolites : monactin, nonactin, valinomycin, staurosporin Bioactivity Antibiotics Immunosuppressive agents Enzyme inhibitors Health effects unknown

40 Sandy Conference Summary Indoor mold recognized as a public and occupational health concern Indoor mold associated with infection, allergy and non-allergic health reactions Mixed health reactions with non-specific symptoms are typical in patients Health care provider lack sufficient education and experience Non-respiratory health problems have been described by clinicians Need for preventive and corrective actions following the precautionary principle Better personal protection (including respiratory protection) often necessary Avoid using biocides in indoor environments and air handling systems during remediation and clean-up many biocides are hazardous to health of workers and home owners!

41 Exposure Hodgson MJ et al :JOEM 1998 ;40: Statratoxins G,H Johanning E et al Indoor Air 9th International conference 2002 Charpin-Kadouch C et al Journal of Applied Toxicology 2006;26: Bloom et al : Appl Environ Microbiol 2007 ;73: Gottschalk C et al Mycopathologia 2008;166: Bloom et al: Indoor Air 2009;19: Hurricane Katrina Brasel TL, Applied and Environmental Microbiology 2005;71:

42 115 = n patients ( ): 225 = n high-volume air samples

43 More than 78 % showed some detectable toxicity, with 19% in the very high category Toxicity Results Roridin A levels no toxicity mild moderate high <2 2 to <5 ng/g 5 to <10 ng/g 10 to <50 ng/g 50 to <100 ng/g >100 ng/g

44 Update of Canadian and international Mold Guidelines and standards by Donald M. Weekes Saratoga Springs Conference Proceedings 2012 New York City Department of Health (NYCDOH) Microbial Guidelines General Accounting Office (GAO) Indoor Mold Report (2008) World Health Organization (WHO) Report Dampness and Mold (2009) Environmental Abatement Council of Ontario (EACO) Mold Abatement Guidelines (2010) US Occupational Safety and Health Administration (OSHA) A Brief Guide to Mold in the Workplace (March, 2010) NY State Toxic Mold Task Force report (2010) American Society of Testing and Materials (ASTM) - Standard Guide for Assessment of Fungal Growth in Buildings (January, 2011) American College of Occupational and Environmental Medicine (ACOEM) Mold Position Statement (March, 2011) Unified Facility Guide Specifications (UFGS) Mold Remediation Specification (May, 2011) Center of Disease Control (CDC) Dampness and Mold in Buildings (May, 2011) American Society of Heating, Refrigeration, and Air Conditioning Engineers (ASHRAE) Mold Position Statement (2011-2) American Industrial Hygiene Association (AIHA) Revised Facts of Mold for Consumers and Professionals (January, 2012) Canadian Municipal Marijuana Grow Op (MGO) Guidelines ( ) National Institute of Occupational Safety and Health (NIOSH) Preventing Occupational Respiratory Diseases from Exposures caused by Dampness inoffice Buildings, Schools and other Non-Industrial Buildings (March, 2011) State of California - Statement on Building Dampness, Mold, and Health (September, 2011)

45 NIOSH RECOMMENDATIONS Moisture-damaged or moldy building materials should be remediated (cleaned and repaired or replaced) precautions taken to prevent remediation workers and building occupants from being exposed to mold or dust during the remediation Prevention and control of building dampness will minimize the chance that occupants will develop respiratory symptoms and disease from exposures related to the dampness.

46 ERMI Although MSQPCR provides a method for identifying and quantifying fungi mold, there had been a lack of a standardized method for describing the mold burden in a home. The EPA readily acknowledged that MSQPCR and ERMI have not been validated or peer reviewed by EPA for public use. The agency considers MSQPCR and ERMI to be research tools not intended for public use.

47 EXECUTIVE SUMMARY A panel of seven scientists selected according to their background and expertise in the fields of interest was invited to review the methods and the recommendations made by the DSP de Montréal. The state of a building can have an impact on health, and the health effects of chronic water infiltration are well recognized. Health effects of damp environments are well recognized, and actions should be undertaken whether there are health effects or not their presence only making the situation more unacceptable. Public release pending French translation

48 Conclusion There is sufficient clinical and experimental evidence to recognize non-allergic toxic health reactions. Research gap: lack of good exposure assessment and correlations with observed toxic health reactions Observed health effects show a need for preventive and corrective actions Precautionary principle

49 Environmental Risk Assessment

50 Outlook Knowing is not enough; we must apply. - J. W. Goethe Bio-marker of exposure and disease Non-allergic health effects Toxicology Neuro-cognitive disorders Cancer? Reproductive hazards? Prevention and Control Population at increased risk Fungal Research Group Foundation

51 Removing lower section of damaged moldy walls enough? Remediation Guideline Publications: Family Doctor A Journal of the New York State Academy of Family Physicians (2013) Journal Environmental Health and Preventive Medicine (Japan; in print, 2014) Environmental Medicine-Hygiene- Occupational Health (Germany 2014) 51

52 Resources:

53 How can mold affect me? Infection Typical organs are the lungs, sinuses and skin? Allergy About 10% of the population is allergic to one or more types of mold Toxicity Is Occurrence limited almost exclusively to immune-compromised patients, including those with transplants, chemotherapy, AIDS, neonates, etc.? Memory loss and cognitive disorders Hair-loss Depression

54 When is mold considered toxic? Mycotoxins are contained only spores Mycotoxins are always present Mycotoxins are also found in mycelia fragments and dust "Current scientific evidence does not support the proposition that human health has been adversely affected by inhaled mycotoxins in the home, school, or office environment." ACOEM Answer*: c

55 What is a safe level of mold in air? There is no specific number that defines either safe or unsafe mold exposure. Some have proposed normal airborne mold exposure levels, however none of these have been adopted by regulatory agencies. For people with allergies to mold no safe level of exposure exists Standards or Threshold Values for airborne concentrations of mold, or mold spores, have not been adopted in the US. Answer*: a-d