Mold Awareness Training 04.27.08 Mold What are the health effects of mold exposure? April 27, 2008. Suite 1000, 8484 Georgia Ave. Silver Spring, MD 20910 Main Phone: 301-578-8500 Main Fax: 301-578-8572 www.cpwr.com Don Ellenberger DOE & EPA Training Director DEllenberger@cpwr.com Phone: 301-495-8504 Fax: 301-578-4190

Mold Awareness Training 04.27.08 Who is affected? v Virtually anyone exposed to airborne mold can react to the toxigenic properties of mold spores. v Asthmatics and others with allergy to mold will react at lower exposure levels.

Mold Awareness Training 04.27.08 Who is affected? v Heavily exposed individuals run the risk of serious illnesses, beyond the toxic and allergic reactions. v Infants and susceptible individuals (e.g., persons with compromised immune systems, living with HIV, cystic fibrosis, and the aged) will likely react at lower concentrations and require special attention. Photo by George Newman, CPWR (November, 2005). Pediatrics ward University Hospital (Tulane University, NOLA).

Mold Awareness Training 04.27.08 Where are we? A lot of time indoors Where do we spend our time? Most mold-related allergy diseases and reactions are prompted by outdoor exposure; however, four prominent outdoor molds are found indoors when windows and doors are left open: Penicillium, Aspergillus, Cladosporium, and Alternaria.

Mold Awareness Training 04.27.08 1. Infections Pathways v Respiratory v Oral v Contact v Penetration Eating/dining/food prep in the home. Multiple pathway opportunities for infectious, allergic, and toxic exposure for the family that occupies this room. Vectors (via insect bite) is a fifth infectious disease pathway. This room’s air is being “scrubbed”. Respiratory = breathing Oral = eating Contact = touching Penetration = open cut/wound and the like. Inhalation -- Most of the heath problems associated with exposure to mold are caused by inhalation Ingestion -- Eating foods contaminated with mold such as grains, nuts, fruits, vegetables, and other foods Skin contact -- Direct contact with contaminated building materials such as wood, paper, fabric, drywall, wallpaper, insulation, carpets, upholstery, and other porous or organic material

Opportunistic Infections Mold Awareness Training 04.27.08 Opportunistic Infections People with weakened immune systems (immune compromised or immune suppressed) may be more vulnerable to infections caused by molds. Aspergillus fumigatus has been known to infect the lungs of immune compromised individuals. When the spores are inhaled the mold begins to grow in the lungs. Infections caused by mold-produced toxins may develop into diseases.

Opportunistic Infections Mold Awareness Training 04.27.08 Opportunistic Infections Athlete’s Foot Molds can cause skin diseases such as athlete’s foot, fingernail/ toenail fungus and other infections such as yeast infection. Case reports and epidemiologic studies show clear association between dampness and disease. Infections can rapidly becomes diseases.

Mold Awareness Training 04.27.08 Infectious Diseases Athlete’s Foot under a microscope Just one type of fungal infection. Shower, pool areas, locker rooms, etc.

Mold Awareness Training 04.27.08 2. Allergic Diseases Asthma, Hay Fever, and more aspergillus under a microscope v Allergic rhinitis (hay fever) v Allergic asthma v Allergic bronchopulmonary aspergillosis -- ABPA v Extrinsic allergic alveolitis -- HP (hypersensitivity pneumonitis) HP = (also extrinsic allergic alveolitis) Farmers lung; generally requires high concentrations; flu-like 4-6 hours after; can lead to fibrosis. Examples of hypersensitivity pneumonitis include: pigeon breeder's disease from exposure to protein particles in pigeon droppings, sauna takers' disease from exposure to mold growing in wet containers, mushroom workers' disease from exposure to moldy compost, and bagassosis from exposure to moldy sugar cane. Hypersensitivity pneumonitis (HP) = Rare, but serious, immune-related condition resembling bacterial pneumonia; may develop after either acute or chronic exposure (via inhalation) to molds; usually related to occupational exposure; can also be caused by bacteria. Chronic (long–term) hypersensitivity pneumonitis causes lung scarring (fibrosis). Symptoms of chronic hypersensitivity pneumonitis include of shortness of breath and cough. ABPA =Allergic bronchopulmonary aspergillosis *Rhinitis: sneezing, itchy eyes, congestion, fatigue, dermatitis *Asthma: 10-15% of children now have asthma; strong association with household dampness; once developed, other triggers can cause reaction. * denotes most common. >Inhaling or touching mold or mold spores may produce allergic reactions in sensitive individuals. >Allergic responses include hay-fever type symptoms, such as sneezing, runny nose, red/ burning eyes, or skin rashes (dermatitis). >Symptoms of exposure may be immediate, delayed or increase in severity over time of exposure. >Mold spores and fragments can cause allergic reactions regardless of whether the mold is alive or dead.

Mold Awareness Training 04.27.08 Allergic Diseases Allergic Bronchopulmonary Aspergillosis – ABPA Aspergillus in the attic Patient with aspergillus-related pneumonia Patient with aspergillus-related tumor in mouth Aspergillus fumigatus Aspergillus favus Mold CFUs in Petri dishes – culture dishes. Lung fibrosis and tumor from ABPA

U.S. Allergy Disease Prevalence Mold Awareness Training 04.27.08 U.S. Allergy Disease Prevalence v 1of 5 Americans suffer from allergic disease v Indoor allergens responsible for significant share v Environmental control reduces disease severity HP = Farmers lung; generally requires high concentrations; flu-like 4-6 hours after Allergic Dermatitis = Rash that occurs when the skin is exposed to certain allergens. ______________________________________________ ABPA = Allergic bronchopulmonary aspergillosis is a hypersensitivity response to the Aspergillus fumigatus, the spores of which are ubiquitous in soil and are commonly found in the sputum of healthy individuals. Repeated acute episodes left untreated can result in progressive pulmonary fibrosis that is often seen in the upper zones and can give rise to a similar radiological appearance to that produced by tuberculosis. Symptoms include wheezing, coughing, fever, malaise, recurrent pneumonia (not affected by antibiotics) expectoration of mucoid plugs containing the fungal hyphae, and unexplained worsening of asthma or cystic fibrosis. _______________________________________________ People with ASTHMA have very sensitive airways that can react to various irritants, making breathing difficult. The number of people with asthma has increased by 59 percent since 1970 to a total of over 9.6 million people. Asthma in children under 15 has increased 41 percent in the same period. The number of deaths from asthma is up by 68 percent since 1979, a total of almost 4400 deaths per year. It is believed that 21 percent of new asthma cases are brought on by occupational exposures to airborne toxins. ____________________________________ Irritant Effects -- Mold exposure can cause irritation to the eyes, skin, nose, throat, and lungs sometimes creating a burning sensation in these areas. Fungi produce Microbial Volatile Organic Compounds {mVOC} during degradation of substrates that cause the “moldy” odor associated with fungal contamination. These compounds can be irritating to mucous membranes, cause headaches, nasal irritation, dizziness, fatigue, and nausea. Eyes, Skin, Nose, Throat, and Lungs are most likely to be the object of irritant effects. Source: NHLBI, 1991

Mold Awareness Training 04.27.08 Allergen Exposure Dust Mites Molds Animal Dander Pollen Allergenic Chemicals Other Exposures Viruses Air Pollution Tobacco Smoke Genetic Predisposition or Susceptibility Immunologic Sensitization Allergic Disease Mild Moderate Severe (Death) Source: Pope AM, et al., eds., 1993

Mold Awareness Training 04.27.08 3. Fungal Toxins Important Mycotoxins Aspergillus favus ……….. Aflatoxin B, Cyclopiazonic acid Aspergillus parasiticus …. Aflatoxin B Aspergillus terreus …….. Citreoviridin Aspergillus versicolor ….. Sterigmatocysin, 5 Ethoxysterigmatocstin Fusarium ………………….. Trichothecene, Zearalenone Fusarium moniliforme …...Fumonisins Penicillium ………………...Citrinin, Patulin Penicillium veridicatum ….Penicillic Acid Stachybotrys chartarum …Trichothecene, Trichodermol, (black mold) Trichodermol Published Mold and their Mycotoxin(s) lists vary in spelling and to some degree, in names of the mycotoxins. Exposure to mold-related toxins may lead to infections which may develop into a disease. Many mycotoxins are highly carcinogenic. There many more toxins than listed here. The term "toxic mold" is not accurate. While certain molds are toxigenic, meaning they can produce toxins (specifically mycotoxins), the molds themselves are not toxic, or poisonous. Hazards presented by molds that may produce mycotoxins should be considered the same as other common molds which can grow in your house. There is always a little mold everywhere - in the air and on many surfaces. There are very few reports that toxigenic molds found inside homes can cause unique or rare health conditions such as pulmonary hemorrhage or memory loss. These case reports are rare, and a causal link between the presence of the toxigenic mold and these conditions has not been proven. Ochratoxin is primarily produced by species of Penicillium & Aspergillus. Ochratoxin damages the kidneys & liver. It is a suspected carcinogen & may be responsible for impairment of the immune system.

Mold Awareness Training 04.27.08 Fungal Toxins Stachybotrys chartarum Black Mold T-2 toxin is a Trichothecene produced by species of Fusarium & Stachybotrys. This is one of the more deadly toxins. If ingested in sufficient quantity, T-2 toxin can severely damage the entire digestive tract & cause rapid death due to internal hemorrhage. It affects human immune and inflammatory systems. It weakens the immune system resulting in viruses, infections and bacteria will have greater chance of making people sick. Possible associate with infants and acute pulmonary hemorrhage. Molds are very common in buildings and homes and will grow anywhere indoors where there is moisture. The most common indoor molds are Cladosporium, Penicillium, Aspergillus, and Alternaria. We do not have precise information about how often Stachybotrys chartarum is found in buildings and homes. While it is less common than other mold species, it is not rare. It can grow on material with a high cellulose and low nitrogen content, such as fiberboard, gypsum board, paper, dust, and lint. Commonly called “Black Mold”. (It is greenish-black). The pictures on this find it on the backing of carpeting/flooring and on the ceiling. Mycotoxins can produce a number of toxic effects in humans. Exposures to Stachybotrys and A. versicolor: central nervous system complaints, headache, nose, throat, irritation, eye irritation, rash, sinus congestion, nose bleeds, and chronic fatigue. There is some suggestion that immune function and neurological effects may be permanent. Fusarium mold can cause disease in many of the foods we eat – as the food is being grown. Fumonisin is a toxin associated with Fusarium species. Fumonisin is commonly found in corn & corn-based products. Fumonisin causes “crazy horse disease”, a liquefaction of the brain. Chronic low-level exposure in humans has been associated with esophageal cancer. Vomitoxin, a trichothecene mycotoxin, is produced by several species of Fusarium. Vomitoxin has been associated with outbreaks of acute gastrointestinal illness in humans.

Mold Awareness Training 04.27.08 Suite 1000, 8484 Georgia Ave. Silver Spring, MD 20910 Main Phone: 301-578-8500 Main Fax: 301-578-8572 www.cpwr.com Don Ellenberger DOE & EPA Training Director DEllenberger@cpwr.com Phone: 301-495-8504 Fax: 301-578-4190