Bioaerosols - The abstracts of The 6 Th international scientific conference on Bioaerosols, fungi, BacTeria, MycoToxins in indoor and outdoor environments and human health. september 6-9, 2011 saratoga springs, new york, usa edited by dr. med eckardt Johanning, M.d., M. sc. philip r. Morey, ph.d. cih pierre auger, M.d. M. sc. Published by the Fungal Research Group Foundation, Inc., Albany, New York
The conference meeting was organized by the Fungal Research Group Foundation, Inc., Albany, New York, USA in cooperation with U.S. ENVIRONMENTAL PROTECTION AGENCY and jointly sponsored with the Mount Sinai School of Medicine. This activity was planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education through the joint sponsorship of the Mount Sinai School of Medicine and the Fungal Research Group Foundation, Inc. The Mount Sinai School of Medicine is accredited by the ACCME to provide continuing medical education for physicians. The production of this publication was made possible with funds from the U. S. Environmental Protection Agency (EPA), Office of Radiation and Indoor Air, Washington, D.C. (http://www.epa.gov/mold/index.html) 2
This edition first published 2012, is copyrighted by registered office/publisher: Fungal Research Group Foundation, Inc., (Johanning MD PC), 4 Executive Park Drive, Albany, N.Y. 12203 USA tel. 518 459 3336; www.bioaerosol.org; www.fungalresearchfroup.com For details of our offices, for customer services and for information about how to apply for permission to reuse the copyright material in this book please contact publisher. The right of the author to be identified as the author of this work has been asserted in accordance with the Copyright Law of the United States of America and Related Laws Contained in Title 17 of the United States Code. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or otherwise, without the prior permission of the publisher. Designations used by companies to distinguish their products are often claimed as trademarks. All brand names and product names used in this book are trade names, service marks, trademarks or registered trademarks of their respective owners. The publisher is not associated with any product or vendor mentioned in this book. This publication is designed to provide accurate and authoritative information in regard to the subject matter covered. It is sold on the understanding that the publisher is not engaged in rendering professional services. If professional advice or other expert assistance is required, the services of a competent professional should be sought. The contents of this work are intended to further general scientific research, understanding, and discussion only and are not intended and should not be relied upon as recommending or promoting a specific method, diagnosis, or treatment by physicians for any particular patient or professional expert recommendation. Indoor environmental conditions often have great variations and differences that change from location to location, building to building. This book covers generic issues and information. The publisher and the author make no representations or warranties with respect to the accuracy or completeness of the contents of this work and specifically disclaim all warranties, including without limitation any implied warranties of fitness for a particular purpose. In view of ongoing research, equipment modifications, changes in governmental regulations, and the constant flow of information relating to the use of medicines, equipment, and devices, the reader is urged to review and evaluate the information provided in the package insert or instructions for each medicine, equipment, or device for, among other things, any changes in the instructions or indication of usage and for added warnings and precautions. Readers should consult with a specialist where appropriate. The fact that an organization or web-site is referred to in this work as a citation and/or a potential source of further Copyright 3
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introduction and overview Since our last meeting in 2003, the body of knowledge regarding indoor and occupational microbial exposure (fungi, bacteria and their allergenic, irritant and toxic by-products) and related diseases with important public health implications has grown significantly. Diseases such as allergy, asthma, inflammatory lung diseases, infections, and cases of mycotoxicosis and neurological or vascular disorders continue to be associated with exposure to bioaerosols. Complex reactions and interactions that result in adverse human health reactions pose great challenges to investigators, clinicians and public health officials. Large scale natural disasters caused be storms and flooding that led to significant water damage and microbial contamination of homes and buildings have occurred in many countries throughout the world: USA, Australia, Pakistan, India, China, England, Poland, Germany, France, Belgium, and elsewhere. In addition to the human tragedy, the costs and technical challenges for cleaning and restoration are tremendous. How do we effectively protect the clean-up workers and the building occupants from harmful microbial contaminants (bacteria, mold, bio-toxins) and exposures? We have learned that poor building and ventilation designs or maintenance, can contribute to increased microbial indoor exposure. Furthermore, the use of watersensitive materials in areas with hot and humid climates, inadequate resources, as well as deficient renovation of existing architectural designs are factors that can lead to indoor mold growth. This has raised international concern about the impact of bioaerosols on the building occupants and workers health. Based on a focus group meeting at the Healthy Buildings 2009 meeting in Syracuse, N.Y., this 2011 Bioaerosols conference addressed the state of art research and practical experience to improve the understanding of microbials (bacteria, mold, bio- and mycotoxins), determine important agents and diagnosis of adverse human health effects, as well as explore new treatment approaches, and the control and prevention of such exposure. Scientific advances and knowledge gaps were discussed. Future research priorities were developed. Precious artwork, books, paper documents and furniture contaminated with biologicals (mold, etc.) often contribute to occupant s exposure and patient complaints. Chemicals (called biocides) intended to kill bacteria and mold also are often harmful to humans and the environment. Little attention has been paid to these issues in hygiene practices and the systematic approach varies in the unregulated cleaning and restoration industry. Some say a building keeps a memory of a contamination, even after careful clean up! Some even suggest that such buildings or items should be condemned and destroyed. We would like to explore the scientific basis for safe materials and practice for the cleaning workers, users and building occupants. Introduction and Overview 5
Clearance criteria for re-occupancy and re-use shall be critically reviewed and any minimum consensus was explored This meeting connected internationally-recognized researchers and leading investigators with front line practitioners and consultants addressing real world problems. We explored the scientific basis for what we do and recommend. 6 Introduction and Overview
conference rationale, goals and learning objective The 6 th International Conference was a forum for the presentation and discussion scientific papers in the field of bioaerosols in order to enhance the knowledge of professionals in the field.. There is a need for enhanced knowledge for health care practitioners and other professionals regarding the proper diagnosis, pathology and treatment of adverse health effects from bioaerosols exposures encountered in the environment and work place, in particular in indoor environments or workplaces that involve handling biological waste products (composting), wet and damp buildings, allergenic and toxic biological by-products from mold and bacteria. The now dated National Academy of Science/ Institute of Medicine scientific committee formulated in 2004 that there is a public health interest in the topic of Indoor Dampness and Health. However, it also identified that there is further research required to learn about the causal connections of certain exposures, biological agents and adverse health effects. The following research gaps were identified (Institute of Medicine (U.S.), 2004): Given the present state of the literature, the committee identified several kinds of research needs. Standard definitions of dampness, metrics, and associated dampness-assessment protocols need to be developed to characterize the nature, severity, and spatial extent of dampness... Any efforts to establish common definitions must be international in scope because excessive indoor dampness is a worldwide problem and research cooperation promoted the generation and dissemination of knowledge. Research is also needed to better characterize the dampness-related emissions of fungal spores, bacteria, and other particles of biologic origin and their role in human health outcomes; the microbial ecology of buildings, that is, the link between dampness, different building materials, microbial growth, and microbial interactions; and dampness-related chemical emissions from building materials and furnishings, and their role in human health outcomes. Studies should be conducted to evaluate the effect of the duration of moisture damage of materials and its possible influence on occupant health and to evaluate the effectiveness of various changes in building designs, construction methods, operation, and maintenance in reducing dampness problems. Indoor environments subject occupants to multiple exposures that may interact physically or chemically with one another and with the other characteristics of the environment, such as humidity, temperature, and ventilation rate. Few studies to date have considered whether there are additive or synergistic interacti- Conference Goals 7
ons among these factors. The committee encourages researchers to collect and analyze data on a broad range of exposures and factors characterizing indoor environments in order to inform these questions and possibly point the way toward more effective and efficient intervention strategies. The committee encourages the CDC to pursue surveillance and additional research on acute pulmonary hemorrhage or hemosiderosis in infants to resolve questions regarding this serious health outcome. Epidemiologic and case studies should take a broad-based approach to gathering and evaluating information on exposures and other factors that would help to elucidate the etiology of acute pulmonary hemorrhage or hemosiderosis in infants, including dampness and agents associated with damp indoor environments; environmental tobacco smoke (ETS) and other potentially adverse exposures; and social and cultural circumstances, race/ethnicity, housing conditions, and other determinants of study subjects health. Concentrations of organic dust consistent with the development of organic dust toxic syndrome are very unlikely to be found in homes or public buildings. However, clinicians should consider the syndrome as a possible explanation of symptoms experienced by some occupants of highly contaminated indoor environments. Greater research attention to the possible role of damp indoor environments and the agents associated with them in less well understood disease entities is needed to address gaps in scientific knowledge and concerns among the public. The WHO Regional Office for Europe commissioned a study and concluded in its 2008 review that the most important health effects of mold and dampness exposures are increased prevalences of respiratory symptoms, allergies and asthma as well as perturbation of the immunological system. (WHO, 2009) The document also summarized the available information on the conditions that determine the presence of mold and measures to control their growth indoors. The guidelines were intended to protect public health under various environmental, social and economic conditions, and to support the achievement of optimal indoor air quality. However, while the guidelines provided objectives for indoor air quality management, they did not provide specific guidelines and strategies for achieving those objectives. The WHO-EU guidelines recommended formulating policy targets, and that governments should consider their local circumstances and select actions that will ensure achievement of their health objectives most effectively. This requires learning the latest research results, risk analysis and communication, team and interdisciplinary work. Physicians, industrial hygienist and air quality specialists and consultants need to better understand the technical exposure assessment methods, language, and successful intervention and control strategies. 8 Conference Goals
In 2010 a New York State Toxic Mold Task Force made up of politically appointed academic and non-academic members issued a report to the Governor and Legislature of New York State regarding the public health status, needs and research gaps. It was concluded that several information and data gaps exist regarding the timely recognition, assessment and control of environmental toxic and non-toxic biologicals (i.e., mold or fungi) in areas of indoor environments, public health and prevention (New York State Department of Health, 2010). The task force states that it focused their analysis on newly-emerging scientific information and on identifying areas where significant knowledge gaps still exist that appear to substantially hinder decision making. Although some criticize that the committee lacked specific inside expertise and apparently failed to consider newer scientific papers and knowledge since the NAS analysis in the early 2000s and should have involved a broader spectrum of experts in the committee, the following conclusion and uncertainties were never the less summarized in their report: Exposure to building dampness and dampness-related agents including mold has been recognized nationally and at the state and local level as a potential public health problem. Asthma and other allergic respiratory diseases that can be exacerbated by mold exposures are common in NYS. This means many people are at risk for exacerbation of their respiratory conditions by exposure to mold conditions in buildings. Evidence for associations between non-respiratory effects and mold exposures in buildings is much more limited and generally does not allow clear conclusions to be drawn one way or the other. Molds, along with other organisms such as bacteria, mites and insects that proliferate in damp buildings, produce volatile compounds, spores and other minute particles that can cause irritant and allergic responses that range from annoying to serious depending on the amount of exposure and the immune system of the individual. Although some molds produce toxins, their contribution to adverse health effects in damp buildings, based on existing scientific information, is uncertain. The 6 th Annual International Scientific Conference on Bioaerosols, Fungi, Bacteria, Mycotoxins in Indoor and Outdoor Environments and Human Health addressed key areas of these identified knowledge gaps and provided scientific research, data, didactic materials and learning opportunities, that shall target change in knowledge, attitude, confidence and beliefs, practice-based clinical skills of health care providers with different professional background and specialty expertise. At the completion of the scientific meeting, the physician, industrial hygienist, health and safety specialist as well as public health officials and other participants gained a wor- Conference Goals 9
king knowledge of practical definitions, science based evidence to apply in their professional practice. RefeRenCes 1. Institute of Medicine (U.S.).Committee on Damp Indoor Spaces and Health. Damp Indoor Spaces and Health. Washington, DC: THE NATIONAL ACADEMIES PRESS; 2004. 2. WHO guidelines for indoor air quality: dampness and mould. World Health Organization WHO Regional Office for Europe. 2009. 3. New York State Department of Health. New York State Toxic Mold Task Force Final Report to the Governor and Legislature. New York State Department of Health - New York State Department of State. 2010. Conference Chair and Director, Proceedings editor: Dr. med. Eckardt Johanning, MD, MSc Co-Editors: Philip R. Morey, Ph.D., CIH. - Gettysburg, Pennsylvania, USA Pierre L. Auger M.D., M.Sc., FRCPC - Montréal, Québec, Canada Conference Organization Fungal Research Group Foundation, Inc. 4 Executive Park Drive, Albany, N.Y. 12203, USA www.bioaersol.org info@bioaersol.org About the Conference Organization: The Fungal Research Group Foundation, Inc. and Dr. Eckardt Johanning organized the first international scientific meeting on Bioaerosols, Fungi and Bacteria, Mycotoxins in Saratoga Springs, New York in 1994, and following in 1996, 1998, 2000 in Helsinki, Finland (together with Healthy Buildings 2000), and in 2003 which brought together a wide range of leading international researchers and health specialists devoted to public health and prevention. Proceeding books of the scientific presentations were published for the 1994, 1998 and 2003 and were made available for generally distribution. Conference Chair and Director Eckardt Johanning, M.D., M.Sc. - Fungal Research Group Foundation, Inc., Albany, New York, USA, Johanning MD PC. E. Neil Schachter, M.D., Prof., Mount Sinai School of Medicine, New York, N.Y., (CME Course Director). 10 Conference Goals
scientific Committee Harriet M. Ammann, Ph.D., D.A.B.T. - Olympia, Washington, USA Pierre L. Auger M.D., M.Sc., FRCPC - Montréal, Québec, Canada Jürgen Bünger, M.D., Prof. - Bochum, Germany Denis Charpin, M.D., Prof. - Marseille, France Jean Cox-Ganser, Ph.D. (NIOSH) - Morgantown, West Virginia, USA Andrew Cutz, B.Sc., CIH - Markham, Ontario, Canada Nceba Gqaleni, Ph.D. - Durban, South Africa Manfred Gareis, D.V.M., Prof. - Kulmbach, Germany Michael R. Harbut, M.D., MPH - Royal Oak, Michigan, U.S.A. Ed Horn, Ph.D.,(NYSDOH,retired) - Albany, New York, USA Laura Kolb, Director, (EPA) - Washington, D.C., USA Kay Kreiss, M.D.(NIOSH) - Morgantown, West Virginia, USA Claude Mainville, P.E. - Montreal, Quebec, Canada Erwin Martlebauer, D.V.M., Prof. - Munich, Germany Robert K. McLellan, MD, MPH - Dartmouth, New Hampshire, USA Mark J. Mendell, Ph.D. - Berkely, California, USA Philip R. Morey, Ph.D., CIH - Gettysburg, Pennsylvania, USA Aino Nevalainen, Ph.D., Prof. - Kuopio, Finland Ed Olmsted, CIH - Garrison, New York, USA Jens Ponikau, M.D., Prof. - Buffalo, New York, USA Tuula Putus, M.D., Prof. - Turku, Finland Thomas G. Rand, Ph.D, Prof. - Halifax, Nova Scotia, Canada Rob A Samson, Ph.D., Prof. - Utrecht, The Netherlands E. Neil Schachter, M.D., Prof. - New York, New York, USA Magdalena Twaruzek, Ph.D. - Bydgoszcz, Poland Jan Grajewski, Ph.D., Prof. - Bydgoszcz, Poland Chin S. Yang, Ph.D. - Voorhees, New Jersey, USA Timothy E. Wallace, RS, CEHP, (FDOH) - Tallahassee, Florida, USA Donald Weekes, CIH, CSP - Ottawa, Ontario, Canada scientific conference coordination Pierre L. Auger M.D., M.Sc., FRCPC - Montréal, Québec, Canada Manfred Gareis, D.V.M., Prof., - Kulmbach, Germany Conference Goals 11
Laura Kolb, Director, (EPA) - Washington, D.C., USA Claude Mainville, P.E., - Montreal, Quebec, Canada Philip R. Morey, Ph.D., CIH - Gettysburg, Pennsylvania, USA E. Neil Schachter, M.D., Prof. - MSSM, New York, New York, USA (CME Course Director) endorsement & support U.S. ENVIRONMENTAL PROTECTION AGENCY Support to present and discuss the latest research results, public health policy and state of the art technical education regarding indoor air and environmental health and prevention The American Board of Industrial Hygiene awarded CM points to Certified Industrial Hygienists certified by the ABIH. University of Natal (South Africa) - Centre for Occupational and Environmental Health Gesellschaft für Mykotoxin Forschung (Mycotoxin Research Association, Germany) 12 Conference Goals
climate change, The indoor environment, and health - study summary By david a. Butler Amid the considerable research on how climate change may affect public health, one subject has received relatively little attention- the impact of climate change on indoor environments and thereby on the health of people who live, work, study, or play in them. No government or private body has lead responsibility for investigating this question, and the lack of leadership is hindering action on identifying potential hazards, formulating solutions, and setting research and policy priorities. Against this backdrop, the U.S. Environmental Protection Agency (EPA) asked the Institute of Medicine to convene an expert committee to summarize the current state of scientific understanding of the effects of climate change on indoor air and public health and to offer priorities for action. Health Problems Here-and May Worsen The committee's report, Climate Change, the Indoor Environment, and Health, points to extensive research on how climate change affects the outdoor environment, how the outdoor environment affects indoor environments under different climate conditions, and how indoor environments affect occupant health, among other related topics. But facing a dearth of research specifically directed at how these factors interact, the committee analyzed and synthesized information from the various independent lines of research. The committee concludes that climate change influences indoor environmental quality, warranting attention and action. The committee based its conclusion on three key findings: 1. Poor indoor environmental quality is creating health problems today and impairs the ability of occupants to work and learn. By one estimate, poor indoor conditions cost the nation's economy tens of billions of dollars a year in exacerbation of illnesses and allergenic symptoms and in lost productivity. 2. Climate change may worsen existing indoor environmental problems and introduce new problems. 3. There are opportunities to improve public health while mitigating or adapting to alterations in indoor environmental quality induced by climate change. Butler 13
Problematic exposures Identified To help in targeting research, the committee identified five major types of climate-induced indoor environmental problems. Indoor air quality. Indoor environments can be contaminated by chemical, organic, and particulate pollutants that migrate from outdoors or that result from gas stoves and other indoor emission sources, such as building materials, radon, and environmental tobacco smoke. Climate change can affect these factors in various ways. For example, changes in the outdoor concentrations of a pollutant due to alterations in atmospheric chemistry or atmospheric circulation will affect indoor concentrations. Measures to reduce energy use in buildings, such as lowering ventilation rates may cause higher exposures to pollutants emitted from indoor sources. The expected increased use of air conditioning, if accompanied by reduced ventilation, could increase the concentrations of pollutants emitted from indoor sources. Additionally, power outages-caused by heat waves or other extreme weather eventscould lead to the use of portable electricity generators that burn fossil fuels and emit poisonous carbon monoxide. Dampness, moisture, and flooding. Extreme weather conditions associated with climate change may lead to more frequent breakdowns in building envelopesthe physical barrier between outdoor and indoor spaces-followed by infiltration of water into indoor spaces. Dampness and water intrusion create conditions that encourage the growth of fungi and bacteria and may cause building materials to decay or corrode, leading in turn to chemical emissions. Poorly designed or maintained heating, ventilation, and airconditioning systems may introduce moisture and create condensation on indoor surfaces. Humid conditions can, however, be improved by welldesigned and properly operating systems. Moldgrowth prevention and remediation activities also may introduce fungicides and other agents into the indoor environment. Infectious agents and pests. Weather fluctuations and climate variability influence the incidence of many infectious diseases. Climate change may affect the evolution and emergence of infectious diseases, for example, by affecting the geographic range of disease vectors. The ecologic niches for pests will change in response to climate change, leading to changed patterns of exposure and, possibly, increased use of pesticides in some locations. Thermal stress. Extreme heat and cold have several well-documented adverse health effects. High relative humidity exacerbates these effects in hot conditions. An increased frequency of extreme weather events may result in more frequent power outages that expose persons to potentially dangerous conditions indoors. The elderly, those in poor health, the poor, and those who live in cities are more vulnerable to both exposure to temperature extremes and the effects of exposure. Those popu- 14 Health - study summary
lations experience excessive temperatures almost exclusively in indoor environments. Building ventilation, weatherization, and energy use. Leaky buildings are common and cause energy loss, moisture problems, and migration of contaminants. Poor ventilation is associated with occupant health problems or lower productivity. Climate change may make ventilation problems more common or more severe by prompting the implementation of energy efficiency (weatherization) measures that limit the exchange of indoor air with outdoor air. The introduction of new materials and weatherization techniques also may lead to unexpected exposures and health risks. Priority Issues for Action and Recommendations In formulating recommendations for ways to reduce the health effects caused by climateinduced indoor environmental conditions, the committee adopted a public health approach founded on three guiding principles. The overall effort, it said, should prioritize consideration of health effects into research, policy, programs, and regulatory agendas that address climate change and buildings; make prevention of adverse exposures a primary goal in designing and implementing strategies to address health effects; and include collection of data to be used in making better-informed decisions in the future. The committee made a number of specific recommendations for actions to be taken by the EPA, in cooperation with other government agencies and with privatesector organizations where appropriate. These actions include: Initiating or expanding programs to identify populations at risk for health problems resulting from alterations in indoor environmental quality induced by climate change and implementing measures to prevent or lessen the problems. Developing or refining protocols and testing standards for evaluating emissions from materials, furnishings, and appliances used in buildings and promoting their use by standards-setting organizations and in the marketplace. Facilitating research to identify circumstances in which climate change mitigation and adaptation measures may cause or exacerbate adverse exposures. Facilitating the revision and adoption of building codes that are regionally appropriate with respect to climate-change projections and that promote the health and productivity of occupants. Developing model standards for ventilation in residential buildings and fostering updated standards for commercial buildings and schools, based on health-rela- Butler 15
ted criteria and aimed at providing a healthful environment under all design and operation conditions. Implementing a public health surveillance system that expands current ongoing surveys to gather information on how outdoor conditions, building characteristics, and indoor environmental conditions are affecting occupant health. Educating the public on issues of climate change, the indoor environment, and health. Evaluating actions taken in response to climate change-induced alterations in the indoor environment to determine whether they are enhancing occupant health and productivity in a cost-effective manner. Spearheading an effort across the federal government to make indoor environment and health issues an integral consideration in climate change research and action plans and, more broadly, coordinating work on the indoor environment and health. COnClusIOn The committee's observations and recommendations are based on scientific evidence that clearly shows that adverse indoor environmental quality is harming people's health. Altered climatic conditions will not necessarily introduce new risks for building occupants but may make existing indoor environmental problems more widespread and more severe and thus increase the urgency with which prevention and interventions must be pursued. Buildings that were designed to operate under the "old" climatic conditions may not function well under the "new." Considering the consequences of climate change adaptation and mitigation actions before they play out and thereby avoiding problems that can be anticipated will yield benefits in health and in avoiding costs of medical care, remediation, and lost productivity. Committee on the Effect of Climate Change on Indoor Air Quality and Public Health John D. Spengler (Chair) Akira Yamaguchi Professor of Environmental Health and Human Habitation, Department of Environmental Health, Harvard School of Public Health, Boston, Massachusetts John L. Adgate Professor and Chair, Department of Environmental and Occupational Health, Colorado School of Public Health, University of Colorado, Aurora, Colorado Antonio J. Busalacchi, Jr. Director and Professor. Earth System Science lnterdisciplin ary Center, University of Maryland, College Park, Maryland 16 Health - study summary