1. Mold: The Fungus Among Us
Roberta Smith, MSPH, RN, CIC, COHN-S, CIH
Occupational Health Program Manager
Colorado Department of Public Health and Environment

2. Today’s Objectives
Understand some different fungal strains and health effects of molds/ fungus.
Learn the EPA recommendations for mold remediation
Understand mold sampling and sampling data interpretation

3. What are Molds?
Mold is a term used to refer to fungi that grown in the form of multicellular thread-like structures called hyphae.
Fungi that exist as single cells are called yeasts.
Molds are fungi that can be found indoors and outdoors.
Mold spores can survive harsh environmental conditions such as dry conditions that do not support normal mold growth.
Break down organic matter (wood, drywall paper)
Fungi release Microbial Volatile Organic Compounds (mVOCs)
Alternaria- Soil, dead organic debris, on food stuffs and textiles. Plant pathogen, most commonly on weakened plants.
Penicillium- Soil, decaying plant debris, compost piles, fruit rot. Commonly found in house dust. Grows in water damaged buildings on wallpaper, wallpaper glue, decaying fabrics, moist chipboard and behind paint.

4. Common Indoor Molds Cladosporium Penicillium Alternaria Aspergillus
Cladosporium: Widespread on many substrates including textiles, wood, moist window sills. Grows at 0° C and so is associated with refrigerated foods.
Penicillium- Soil, decaying plant debris, compost piles, fruit rot. Commonly found in house dust. Grows in water damaged buildings on wallpaper, wallpaper glue, decaying fabrics, moist chipboard and behind paint.
Alternaria- Soil, dead organic debris, on food stuffs and textiles. Plant pathogen, most commonly on weakened plants.
Aspergillus- Found on a wide range of substrates. Water requirements range widely. Soil, decaying plant debris, compost piles, stored grain.

5. “Black Mold”- Stachybotrys
Stachybotrys is less common in indoor environments
Rarely found in isolation, always occurring in the presence of other fungi.
Stachybotrys exists worldwide.
Color of indoor molds does not determine if they are toxigenic or not.
Organism is found in soil and strata rich in cellulose
Hay
Straw
Grain
Hemp
Plant debris
Dead roots
Wood pulp
Cotton
Fabrics
Paper
Book bindery glue
Cigarette tobacco

6. Rationale for concerns regarding Stachybotrys
Equine outbreaks and anecdotal reports suggested that the fungus could exert at least minor pulmonary effects.
Concerns in the US developed primarily due to reports linking an unusual cluster of pediatric idiopathic pulmonary hemorrhage.
1994 and 1997 CDC reported clusters of IPH among infants in Cleveland, OH.
Reviews by CDC staff and external consultants identified shortcoming in the conduct of the studies.
No supportive evidence for serious illness due to Stachybotrys exposure in the contemporary environment.
Subsequently, the CDC published a retraction of its support
of the papers’ conclusions (61–64), due to apparent shortcomings
of the aforementioned studies. The CDC stated that, because
of insufficient evidence, an association between S. chartarum
and infant IPH was not proven. T
he reviewers felt that the diagnoses of
cases were inadequate and the source of cases was inconsistent
(61, 64). There was no consistent definition of lung disease, a
problem typical of the indoor-mold literature

7. Typical Outdoor Spore Levels, Colorado
Spores/ m3
Fungal Type
Low
Medium
High
Frequency %
Alternaria 13 40
107 50
Basidiospores 53
187
747 81
Botrytis 2
Cladosporium 93
287
1067
Penicillium/ Aspergillus types
160
427 74
Stachybotrys
Typical outdoor spore level data presented are the top spore types complies from the EMLab P&K database of outdoor spore samples for representative states. The last column represents the frequency of occurrence. The low, medium and high values represent the 2.5%, 50% and 97.5% percentile values of the spore count when that spore type is detected.
Source: EMLab P&K IAQ pocket reference guide- 7th ed.

8. Fungal Infections Anyone can get a fungal infection
Opportunistic Infections: Infections that happen because a person’s immune system is weak
Hospital-Associated Infections: Infections acquired in a healthcare/ hospital setting
Community-Acquired Infections: Caused by fungi that live in the environment in specific geographic areas.

9. Community-Acquired Coccidioides immitis Histoplasma capsulatum
Blastomyces dermatitidis
Coccidioides immitis= valley fever. The fungus is known to live in the soil in the southwestern United States and parts of Mexico and Central and South America. Its difficult to prevent exposure in areas where it is common.
Histoplasmosis- Lives in soil that contains large amounts of bird or bat droppings.
Blastomyces- lives in the environment particularly in moist soil and in decomposing organic matter such as wood and leaves.

10. How can you acquire these fungal infections?
Traveling to an area where the causative fungus is common raises the risk for infection.
No prior exposure
Occupational exposure
Serious infections occur in those with a weakened immune system.
Cancer
HIV
Chemotherapy
Glucocorticoid medications

11. Opportunistic/ Hospital Acquired Fungal Infections
Candida albicans
Aspergillus
Zygomycetes (Rhizopus, Rhizomucor, Absidia, Mucor sp.)
Cryptococcus neoformans and C. gatti
Cryptococcus neoformans is a fungus that lives in the environment throughout the world. People can become infected after breathing in the microscopic fungus, although most people who are exposed to the fungus never get sick from it. Infections are extremely rare in people who are otherwise healthy.
Cryptococcus gattii primarily lives in tropical and sub-tropical areas of the world.

12. Mycotoxins Molds that produce mycotoxins are called toxigenic
Toxic mold is an inaccurate statement.
Presence of mold in a building does not necessarily mean that mycotoxins are present.
ingestion,
contact or
inhalation of airborne particles.
Exposure can occur through:

13. Mycotoxins cont.
Aflatoxin B1 has been found on contaminated grains, peanuts, and other human and animal foodstuffs.
Aspergillus flavus and A. paracitisus not commonly found on building materials or in indoor environments.
Aflatoxin B1 is most well known- produced by molds Aspergillus flavus and A. paracitisus and is a carcinogen.

14. Microbial Volatile Organic Compounds (MVOCs)
MVOCs are composed of low molecular weight alcohols, aldehyde, amines, ketones, terpenes, aromatic and chlorinated hydrocarbons, and sulfur-based compounds, all which are variations of carbon-based molecules.
Very low odor threshold- easily detectable by smell.
Strong odors “old cheese” “dirty socks” or “locker room” smells associated with mold and bacterial growth.
The perception of MVOCs is an indication that microbial growth is occurring.
Potential to elicit health effects remains speculative.
In the indoor environment, exposure to fungal MVOC's has been blamed for headaches, nasal irritation, dizziness, fatigue, and nausea. However, evidence is inconclusive on this point, and other factors should also be considered. A few studies have attempted to document the effects of direct exposure to MVOC's, but none have unequivocally documented a connection with any health effect at any concentration commonly measured in contaminated buildings. 

15. Mold Allergens Spores are allergenic
Associated with IgE-mediated diseases such as asthma, rhinosinusitis.
May also be involved with colonization of allergic host, e.g. ABPA, allergic fungal sinusitis.
Outdoor exposures are more relevant in terms of sensitization and disease expression as most allergen exposure occurs outdoors.

16. Hypersensitivity Pneumonitis
HP is an uncommon but important disease that can occur as a result of mold exposure, particularly in occupational settings with high levels of exposure.
Disease (Common Name)
Antigen
Source
Farmer’s Lung
Thermophillic actinomycetes
Moldy hay, grain, vegetables
Pigeon breeder’s lung
Pigeon, parakeet, chicken, turkey proteins
Avian dropping or feathers
Cheese washer’s lung
Penicillium casei
Moldy cheese
Coffee worker’s lung
Coffee bean dust
Coffee beans
Malt worker’s lung
Aspergillus fumigatus or A. clavatus
Moldy barley
With recurrent attacks, collagen deposition may occur, leading to chronic irreversible fibrosis.

17. Asthma
There is extensive evidence to document that exposure to fungi can precipitate asthma attacks.
May be involved in the initial development of asthma in some circumstances
Childhood asthma studies
Work related asthma studies.

18. IOM report 2004, Damp Indoor Spaces and Health
Evidence supporting an association between the presence of mold (otherwise unspecified) indoors and certain health effects
Sufficient evidence
Limited or suggestive evidence
Inadequate or insufficient information
upper respiratory symptoms
cough
wheeze
asthma symptoms in sensitized asthmatic persons
hypersensitivity pneumonitis (a relatively rare immune-mediated condition) in susceptible persons
respiratory illness in otherwise healthy children
a variety of other health outcomes, including acute idiopathic pulmonary hemorrhage in infants
In 2003 the CDC asked the Institute of Medicine (IOM) to review all scientific studies to date about the possible connection between damp and moldy indoor places and problems with breathing or allergies.
Conclusions:
The growth of some bacteria (germs) and molds is one effect of indoor dampness. Damp indoor environments also benefit house dust mites. Standing water supports cockroach and rodent (rats and mice) problems as well. Too much moisture may cause toxic chemicals to be released from building materials and furnishings.
Mold spores are found in indoor air and on surfaces and materials. No indoor space is free of them.
Damp indoor spaces may also allow the growth of bacteria that can cause negative health effects.
Controlling moisture is the main way to control indoor mold growth.
Many ill effect due to mold are more associations with not much proof of causation.

19. Now you know your molds and health effects…
Let’s learn how to prevent them!

21. The key to mold control is moisture control
Mold Prevention
The key to mold control is moisture control
Fix leaky plumbing and leaks as soon as possible.
Watch for condensation and wet spot- fix source(s) of moisture
Prevent moisture due to condensation by increasing surface temperature or reducing the moisture level in air
Insulate or increase air circulation
Keep HVAC drip pans clean, flowing properly, and unobstructed
Vent moisture-generating appliances to the outside where possible.
Maintain low indoor humidity (30-50%)
Perform regular building/ HVAC inpsections
Clean and dry wet or damp spots within 48 hours
Don’t let foundations stay wet.
Source: EPA : Mold Remediation in Schools and Commercial Buildings

22. Water Damage- Cleanup and Mold Prevention
Source: EPA : Mold Remediation in Schools and Commercial Buildings

23. Questions to Consider Before Remediating
Are there existing moisture problems in the building?
Have building materials been wet more than 48 hours?
Are there hidden sources of water or is the humidity too high (high enough to cause condensation)?
Are building occupants reporting musty or moldy odors?
Are building occupants reporting health problems?
Are building materials or furnishings visibly damaged?
Has the building been recently remodeled or has building use changed?
Is consultation with medical or health professionals indicated?
Source: EPA : Mold Remediation in Schools and Commercial Buildings

25. Mold Investigation Strategies
Hypothesis
Develop preliminary hypothesis from initial contact
Visual Inspection
Plan and carry out visual inspection
Revisit Hypothesis
Revisit hypotheses and create new ones if necessary
Sampling
Decide if sampling is needed
Conduct sampling and analysis
Interpret Data
Interpret data
Make recommendations

26. Develop a TESTABLE Hypotheses
Clear, concise, well-defined
Results in a Yes or No answer
Can be proven by direct measurements.
Good Hypothesis: The area’s Pen/Asp concentration is not detected.
Bad Hypothesis: All of my employees are ill due to mold.

27. Sampling
If there is visible mold or obvious water damage, sampling is usually not necessary.
Sampling should only be conducted when you have specific goals and the inherent problems with sampling are understood.
You might want to sample to ATTEMPT to:
Document whether there is an indoor source of mold growth.
Determine the cause of a specific diagnosed diseases.
Determine the effectiveness of a mitigation program.

28. Mold sampling methods Source Samples Air Samples Settled Dust Sampling
Tape samples or bulk samples
Cultured or analyzed by microscopy
Air Samples
Non-viable samples
Analyzed by microscopy
Viable samples
Cultured, identified, and counted
Settled Dust Sampling
Vacuum Samples
Cultured or analyzed by PCR techniques
Gas/Vapor sampling for mold metabolites

29. Interpreting Results
No generally accepted health-based standards for mold exposure
There is a large sample to sample variability for both viable and non-viable mold samples.
Goal is to determine whether there is a source of mold growing indoors
Compare indoor samples with outdoor or control area samples collected at similar times
Large increases (10 fold or more) in numbers of the same mold types indoors as compared to outdoors considered evidence of possible indoor mold growth.
Difference in the types of mold genera or species between the two samples may be suggestive of indoor mold growth.
Need to understand conditions of the day samples were taken
Outdoor weather conditions, indoor activities, etc.

30. Molds in your sample that can be indicators of an indoor source
Molds that prefer cellulose, moisture, and nutrient poor settings
Stachybotrys
Cladosporium
Penicilium
Aspergillus
Stachybotrys can sometimes be isolated from other substrates including pipe insulation, gypsum, fiberglass wallpaper and aluminum foil.

31. Interpretation Sample – Project B
Slide used with permission from EMLab P&K

32. Understanding conditions
Traffic in area
Outdoor conditions (windy day, raining, snowing?)
What was going on in sampling area.

33. Moldy Persimmon Toss Slide used with permission from EMLab P&K
Note increase in smut (or periconia)
Slide used with permission from EMLab P&K

34. How to Avoid Mold- “Healthy Homes” Approach
Keep it dry
Keep it clean
Keep it pest-free
Keep it ventilated
Keep it contaminant- free

35. Today’s Objectives
Understand some different fungal strains and health effects of molds/ fungus.
Learn EPA recommendations for mold remediation
Understand mold sampling and sampling data interpretation

36. Resources
EPA Mold Remediation in Schools and Commercial Buildings: commercial-buildings-guide
A Brief Guide to Mold, Moisture, and your home 10/documents/moldguide12.pdf
CDC Mold After a disaster

37. References EMLab P&K- IAQ Pocket Reference Guide- 7th edition
Special thanks to Ivan Hsieh and Dave Gallup to use slides 31&33 from EMLab P&K.
Centers for Disease Control and Prevention
NIOSH: