Translating Scientific Reports Into Usable InformationPage 1 of 8
TRANSLATING SCIENTIFIC REPORTS INTO USABLE INFORMATION:
Medical Science Continues to Tie Mold Exposure to Significant Health Effects
Michael A. Pinto, CSP, CMP
A Connection between Scientific and Legal Issues
In March of 2012 the appellate court of the state of New York surprised many legal observers by issuing an opinion that reopens the door to mold lawsuits in that state for cases involving personal injury claims. This was big news because for many years courts around the country have severely limited discussions about mold injuries by stating that plaintiffs could not prove that the scientific theory connecting mold and dampness to illness is generally accepted by the scientific community. Now, however, the appellate court of a major state has significantly softened their stance and stated that scientific and medical studies brought forward in a suit between a renter and her landlordwere "statistically significant" and demonstrated "that exposure to mold caused the identified ill-health effects."
Although detailed evidence needs to be producedin each case to prove or disprove a connection between fungal contamination and illness, these specific reports are put in an overall context by broader research that provides an understanding of the mechanisms of how contaminants from damp environments impact the body. Since the volume and intellectual weight of this general research has grown rapidly over the last five years, it was only a matter of time before the courts were forced to take another look at their rejection of the notion that mold exposure can cause a variety of debilitating illnesses such as fatigue, memory loss, and other neurological issues.
Advancing Scientific Information
That is why the information presented ata small gathering of international scientists in September 2011 in Saratoga Springs, New York, is so important for anyone dealing with fungal contamination or mold remediation. The title of this conference was as weighty as the subject matter: The 6th International Scientific Conference on Bioaerosols, Fungi, Bacteria, Mycotoxins in Indoor and Outdoor Environments and Human Health. While some conferences claim to be international in scope, this one really was. In addition to support from the United States Environmental Protection Agency, the South African Center for Occupational and Environmental Health and the German Mycotoxin Research Association also were prime movers for the event. A cadre of American speakers was complemented by individuals from Canada, Finland, Germany, France, Poland, Chile, Saudi Arabia, Switzerland, and South Africa with poster or presentation sessions.
The conference was organized and led by Dr. Eckardt Johanning, an individual who has been at the forefront of understanding fungal related diseases for more than 15 years. In 1994 Dr. Johanning organized the first of these events, with other programs following in 1996, 1998, 2000, and 2003. The 2011 conference was dizzying in the range of topics and depth of knowledge that the speakers exhibited. While many of the presentations were geared for medical practitioners and biologists, there was much that the layperson could take home, as well. While I have summarized below in simplified terms some of the sessions that should be of interest to anyone dealing with mold, the overall impression of the conference is what was most important. The evidence is increasingly clear that current research is not only validating the connection between water-damaged buildings and ill-health, but also explaining the mechanisms that cause the problems.
Acute Pulmonary Hemorrhage in Infants: Cleveland Update
Perhaps the most interesting session of the entire conference was an update on one of the first cases that brought potential mold health problems to the public consciousness. In 1994 Dr. Dorr Dearborn called the Centers for Disease Control (CDC) for assistance when he was working at Rainbow Children's Hospital and treated four babies in just two days for a mysterious bleeding lung ailment.
Dr. Dearborn noted that the original CDC-led investigation of the first ten cases implicated water-damaged houses and the presence of the toxigenic mold, Stachybotrys chartarum. Although a secondary review by the CDC of their original case-control field study was critical of it and discounted its findings, the original research team has accepted neither that review nor the CDC’s revised conclusions.Rather than merelyaccept the second CDC report that significantly downplayed the connection between mold and lung bleeding (a decision that many people—including individuals at the CDC—believe was done strictly to quell the public panic about mold), a small team of doctors and environmental professionals have continued to investigate similar cases in the Cleveland area.
In the intervening 17 years this group has built their database to 52 cases of acute pulmonary hemorrhaging in infants. They havebeen able to investigatefor fungal species in 43 of the homes where the infants resided. The findingsare persuasive with 39 (91%) of the residences contaminated with Stachybotrys chartarum, consistent with eight of nine homes in the original study. Similarly, 88% ofthe homes had visible water damage, with 71% of the infants exposed to environmental tobaccosmoke (ETS). Both of these parameters are also consistent with the original study.
In addition to the continued connection of lung bleeding to identification of Stachybotrys in the homes of the patients, fungus was identified in the respiratory secretions of some of the ill infants.The research team lead by Dr. Dearborn also looked at animal studies to better understand the process that was causing lung bleeding. He reported that at least ten publications from four different laboratories have uniformly reported pulmonary hemorrhage in animal studies where Stachybotrys spores are put into the airways of rodents.
What they foundfrom the animal tests (which lines up with the observation of their patients) is that some of the mycotoxins (chemical poisons) associated with Stachybotrysinhibit proteinsynthesis,which is necessary for the proper development of rapidly growing, immature lungs. Additional mechanisms relatedto protein degradation and mycotoxin-driven inflammation arealso likely to be involved in the breakdown of the small blood vessels that result in lung bleeding.
After summarizing the mold-related factors for bleeding lungs, Dr. Dearborn also reminded the listeners of other potential contributing factors such as bacterial endotoxin in water-damaged homes, and frequent parallel exposure to environmental tobacco smoke. In this respect the presentation supported the move toward thinking of these medical issues as related to water-damaged buildings (WDB) rather than just mold.
Toxic Droplets Produced by Stachybotrys
A fascinating corollary to the Dorr Dearborn presentation was offered several days later by German scientists as they explained how Stachybotrys produces poisons. They began the presentation by informing the audience that in addition to taking in moisture for growth, fungal organisms excrete a variety of liquid chemical compounds. The technical term for the production of liquid droplets on the surface of mold structures (known as mycelia and hyphae) is "guttation". For the layperson the presenters called these droplets “toxic bombs”. They stated that their research indicates that there are more poisons in the droplets than in spores or hyphae.
Although guttation has been understood scientifically for over 120 years, most of the effort has been focused on Aspergillus and Penicillium species as part of the antibiotic production process. A previous studywas referenced thathad demonstrated that droplets produced by many Penicillium species contain highamounts of the mold-produced poisonOchratoxin A, which damages the kidneys.
The scientistsexplained that the purposeof the follow-up study was to examine whether the phenomenon of guttation is also a feature ofStachybotrys isolates, and whether toxic chemicals are part of the excreted droplets.Their study provided a definitive "yes" to both of those questions.
The researchers took 30 samples of Stachybotrys mold that mostly came from water-damaged materials such as wallpaper and drywall. They cultured the mold and then observed the colonies under a microscope, where they were able to photograph the droplets being produced by the fungal structures. After collecting and analyzing the liquids, they verified that Stachybotrys produces chemicals in the droplets that are known to damage the nervous system (i.e., poisons known as trichothecenes—specifically satratoxin G, satratoxin H, androridin E).
NIOSH Field Studies on Dampness and Mold and Related HealthEffects
One of the most interesting aspects of the conference was how various presentations were interrelated and brought about a better understanding of mold, particularly in regards to adverse health effects. The presentation from representatives of the National Institute for Occupational Safety and Health (NIOSH) was one that summarized information from a number of their own studies and served as a bridge to information from other presentations.
The NIOSH information re-emphasized that adverse health effects are related to exposure to a number of contaminants that come from damp buildings, including mold, bacteria, and physical allergens such as dust and fiberglass. Because they were field studies of actual water-damaged buildings, the NIOSH staff has been able to link occupancy in such structures to a poorer quality of life. The detrimental effects noted in multiple investigations included increased sick leave and medication use, respiratory illnesses, and the onset of asthma.
The NIOSH researchers developed a building scoring system based on a standardized assessment of dampness and mold, as well asmeasures of hydrophilic (water loving) fungi and ergosterol (a component of fungal cell walls). They correlated this survey information with symptoms and found it to be a good indicator of adverse health effects. They also looked at endotoxin (a component of Gram-negative bacteriacell walls) and discovered thatexposure to such bacterial elements may change the effect of fungal exposure on respiratory health. In essence, the government scientists reinforced the idea that there is a synergy between various contaminants in water-damaged buildings that can magnify the bad health effects experienced by occupants.
Another fascinating discussion centered on NIOSH’s review of reports about visual contrast sensitivity (VCS) testing being used to assess occupant exposure to water-damaged buildings. VCS has previously been used in studies of exposure to toxins that attack the nervous system in situations otherthan damp indoor environments. A recent health hazard evaluation report by NIOSHinvestigators from Cincinnati described lower visual contrast sensitivity in staff at a severely water-damagedschool than in staff at a school without significant water damage. While thestudy has limitations, with NIOSH continuing to evaluate this diagnostic tool its use is expected to grow in the next few years.
Observational Epidemiology and Indoor Mold Exposure: Selected Case Studies
In this presentationJoseph Q. Jarvis, a physician in Salt Lake City, explaineddata that he accumulated from studies of four large non-residential buildings with water intrusion problems and occupant complaints. He was blunt in his assessment that “observational epidemiology” (i.e., investigating to find the causes of disease) confirms that both symptoms of irritation of the respiratory system and allergic chest disease may occur in water-damaged buildings with indoor mold levels that do not reflect a normal fungal ecology.
He noted that the irritation symptoms (cough, raspiness, sore throat, mild chest pain, etc.) tend to dissipate relatively soon after remediation or removal from the building. He speculated that this rapid recovery was probably because these symptoms represent non-specific irritation of mucous membranes through direct contact with mold particulates. In contrast, allergic chest symptoms remain elevated for an extended time after remediation or removal from exposure due to the chronic inflammatory changes associated with acquired hypersensitivity to mold antigens.
These cases corroboratedother studies that show that extensive mold proliferation in a water-damaged building may cause an increase in irritation symptoms within a few days or weeks. However, the onset of allergic respiratory disease apparently requires a sustained (several months)unusual mold exposure.The really good news from Dr. Jarvis’ studies is that heavily water-damaged buildings can be remediated such that even occupants with acquired hypersensitivity and allergic respiratory disease can safely re-occupy the space.
Rhinosinusitisand Mold as Risk Factors for Asthma Development in Water Damaged Building Occupants
Although the title of this presentation was intimidating, the information presented was straightforward. Also, it offered support to the medical theories discussed in the Salt Lake City case studies (see previous section), andthe fact that it was another NIOSH presentation gave it additional credibility.
To better understand the presentation it is important to have a graspof the terminology. Rhinosinusitis refers to the inflammation of the tissues of the nose (rhino) and the sinuses. It usually occurs after an allergic reaction or viral upper respiratory infection.The Certified Industrial Hygienist (CIH) from NIOSH reaffirmed that in occupants of damp buildings mold exposure has been associated with nasal symptoms and asthma development. However, the progression from building-related rhinosinusitis to asthma due to mold exposure has been poorly understood.
Therefore, NIOSH conducted a number of statistical surveys of occupants in water-damaged buildings, with controls for extraneous factors such as demographics, smoking status, years of building occupancy, bacteria levels (endotoxins), and fungi levels. Their statistics indicate that building-related upper respiratory symptoms in occupants of water-damaged structures predict an increased risk of developing more serious lower respiratory illnesses such as asthma. This correlation is particularly strongfor occupants that aresubjected to high mold levels and other dampness-related exposuresafter they begin suffering from the irritation symptoms described in the Salt Lake City case study presentation.
Does Reversibility of Neurobehavioral Dysfunction have Diagnostic and PossibleTherapeutic Use in Mold/Mycotoxin Exposed Patients?
This fascinating information did not even make it to a presentation and was offered as a poster. Dr. Kaye H. Kilburn, M.D., moved from investigation to possible treatment of mold induced symptoms because he knew that certain anti-inflammatory compounds are used to treat nervous system problems caused by chemical exposures such as those from industrial solvents.
The physician began by confirming that mold induced irritation of skin, nose, upper airway, and lung coincided with inflammation-oxidation of the brain. This nervous system inflammation appears to be from the mycotoxins and other chemicals in molds. This led to the idea to try administering substances known to break down contaminants in the body by reduction and oxidation (known as redox agents). He measured their effectiveness by testing the patients’ balance, reaction time, color discrimination, visual fields, grip strength, and hearing, and by administering psychological tests.
The short term results were impressive. A redox agent given via nasal spray improved neurobehavioral functions—including balance, problem solving, grip strength, and color discrimination—in mold/mycotoxin exposed patients. These improvements were observed after 30 days or less of treatment. Unfortunately, after stopping the use of the redox agents the patients returned to pretreatment levels in two days.
Mycotoxins and WHO 2009 Report Dampness and Mould: ACase of Incomplete Literature Review
A Canadian physician offered a short presentation to point out that the authors of the 2009 World Health Organization (WHO) report, “Guidelines for Indoor Air Quality: Dampness and Mould,”were too conservative in their statements about mold poisons. He noted that the WHO document states that evidence of theeffects of mycotoxins on human health in indoor air situations is extremely weak. In contrast to that position, the doctor referenced a multitude of scientific publications in the last ten years indicatingthe contrary, which he dubbed “a logarithmic surge of evidence”. He believes that the medical profession is best served by summarizing this existing information on the toxic effects of bio-contaminants associated with dampness and then putting the emphasis on preventive and corrective actions.
Indoor Water and Mold Damage — German Investigation and DecontaminationPractices
A detailed explanation of a large number of investigative studies in Germany that started with occupant complaints and followed all the way through to remediation of the structure and treatment of the patients revealed a number of important lessons. One of the most basic conclusions was that health problems related to mold contamination is a worldwide phenomenon. The significant increase in these cases in the last 15 years goes hand-in-hand with efforts to make buildings more energy efficient in response to both incentives and regulations.