Indoor Air Quality Mold in the schools By

Indoor Air Quality: Mold in the schools By Chris Randolph, M. D. Associate Clinical Professor Yale Affiliated Hospitals Waterbury, CT

Learning objectives: Outlines To familiarize the healthcare provider with: 1. Mold associated illness in schools: a. b. c. 2. The Role of fungi in the Environment. The health impact on schools. The role of toxigenic fungi. Diagnosis and remediation of mold in the school.

Definitions o o o Fungus Gr sponge: ”Any of a large division of thallophytes including molds, mildew, mushrooms, rusts and smuts, which are parasites on living organisms or feed upon dead organic matter” Reproduce by spores and lack chlorophyll, true roots, stems or leaves. (Webster’s New World Dictionary 3 rd college edition 1994 Mac. Millan p 546 -7) Mold is “downy or furry growth on the surface of organic matter caused by fungi especially in presence of dampness or decay. ” (Webster’s New World Dictionary 1994 p 873)

Definitions o Fungal Related Chemicals: o o Metabolites: Toxins Components or byproducts (VOC): Ergosterol, B(1 -3) glucan, VOC (volatile organic compounds) Mycotoxin: nonvolatile secondary metabolite of filamentous fungi that is toxic to vertebrates Produced by many fungal spores and many toxins by same species i. e. Penicillium, Alternaria, Aspergillus, Fusarium as well as Stachybotrys. (Webster’s 1994/ Google) (Muilenberg M Current Views All/Imm 2004)

CASES: Mold Associated Illness in Water Damaged Schools Ø Ø 12 y/o w/f developed new onset “asthma” in a school adjacent to a waterfall. Middle school children developed nonspecific rash, cough and/or influenza- like symptoms in a newly constructed school. High School guidance counselors developed influenza - like symptoms Remediation with decline in symptoms

Introduction: Ecology Mold represents a generally benign saprophyte Manufacture of antimicrobials to cheese Now health concern stifling home sales, increasing insurance, affecting schools and taxpayers as well with poorly documented health problems Texas insurance companies /Ed Mc. Mahon/Michael Jordan/School closures/State Farm and others eliminate coverage/millions in suits for attorneys (“Mold is gold”). Chapman. JA et al: Toxic mold: phantom riskvs science. Ann. Allergy 2003: 91; 222 -32

Belkin L. Haunted by mold. NYTimes Magazine 8/12/2001 p 28

Ecology (Chapman 2003) n n n Present 559 million years ago or earlier in peaceful coexistence Absorb water from soil, wood, decaying organic matter Size microscopic to some of large, multi cellular organisms (6. 5 km 2 in Washington State(3 counties): Armillaria ostoyae fungus) Include 1. 5 million species / 100, 000 identified / 10 primary pathogens remainder saprobic Include toadstools, mildews, puffballs, yeasts, smut, rusts occupy 25% of earth biomass Perfect and imperfect classes Chapman JA, et al. Toxic mold: phantom risk Vs science. Annals Allergy, Asthma, Imm. 2003; 91: 222 -232

Ecology (Chapman 2003) Common indoor Common. Outdoor: Cladiosporium Penicillium Aspergillus Alternaria Aureobasidium Basidiospores Cladiosporium Ascospores Alternaria Penicillium Aspergillus These require continuous O 2, water, organic material and suitable temperature for growth. n n n n Chapman. JA et al Ann. All. 2003; 91: 222 -32 (Healthy. Schools Network, , Albany, NY. www. healthyschools. org n n Acremonium: produces toxin Alternaria: carpets, textiles, window frames in building interiors Aspergillus flavus water damaged carpets, Aspversicolor damp wood or wall paper glue Cladosp. in supply ducts Stachybotrys greenish black grows on cellulose Penicillium produce mycotoxins (Pexpansum, Pchrysogenum) Fusarium in humdifiers Trichoderma in paper source of antibiotics toxic to humans

Fungi: growth conditions Atmospheric conditions : n Require 70 -90% relative humidity n Grow optimally at 20 -40 o C n Wide variety host requirements n Some grow in hot, dry climate (xerophilic) n (Terr A. The role of mold in disease. Am. Acad. All. Asthma. Imm meeting: San Francisco, California 3/04) n

Fungi: Habitat n n n n Outdoors: Ubiquitous: airborne globally except polar caps Indoors 30 -70% of outdoors From outdoor penetration Or indoor source i. e. plant or garbage Primary host: plant especially crops Saprophytic colonization or pathogenic (invade tissue) (Terr A. The role of mold in disease (and non-disease. AAAAI 3/04)

IMPACT OF FUNGI ON HEALTH ? Agent n Source n Pathway n Adequate dose n Outcome n Null hypothesis: Damp, cold and moldy environments are not associated with poorer health. n

Fungi o o Areas of medical concern Allergens Infectivity Toxins Terr A. The role of mold in disease and nondisease. Am. Acad. All. Asthma Imm. Meeting. San. Francisco , California , 3/04.

Toxic mold: phantom risk vs science n n n n n Mold associated disease : need for controls and standards for exposure Length exposure and individual sensitivity 4 categories: Anecdotal evidence Case studies Epidemiologic studies Experimental evidence Consequences of low level mold unknown Synergism with indoor aerosols Mold panic replace with science Burge, Annals 2003; 91: 217 -219 Chapman et al Annals All 2003; 91: 222 -232

Dales RE, Cakmak. S, Burnett. RT, et al. Am J Resp. Crit Care Med 2000; 162(6): 2087 -90.

Indoor Air Quality in Schools (Dishop, 2002) n n n Airtight schools : 1960 -1970”modular format “was walled in w/o installation of adequate air circulation. (Morris, AB. Does design make a difference? Conf AIAComm Arch. Educ. AIA 1997) Poor maintenance leads to water injury medium for mold and fungal allergen Sources indoor air quality: covered air supply, return ventilation, improperly maintained radiator and air filters, ins. sealed cleaning and maintenance chemicals. Wooden construction >concrete (Meklin T. AIHA Journal 2003; 64: 108 -116) Other sources classroom pets, second hand smoke, labs, copier, furnace room vents and ventilation system, water and moisture injury, eating facilities, upholstered furniture. Children most vulnerable particularly with allergic rhinitis and asthma per Institute of medicine because they are low to ground have less body mass and breath more rapidly. AAP Statement: Damp mold ridden environment is unhealthy particularly for individuals with respiratory conditions. Dishop ML. Maintaining Environmental Cleanliness in School. Suppl JSch. Nursing 2002 (Oct): 23 -26

Dishop. ML. Maintaining environmental cleanliness in school. Suppl. JSch Nurs October 2002.

Total airborne and viable fungi in schools n n n Total airborne (Daisey et al Indoor Air 2003) and surface fungi in 13 classrooms in 6 Florida schools in 10 papers. Health complaints: stuffy sinuses, sore throat, respiratory illness, lethargy, itchy eyes and runny nose. Concentration >1000 CFU/m 3 in one complaint and non-complaint all others <700 CFU/m 3 (Bates and Maffy, 1996) Average and maximum total viable molds measured in 96 classrooms in 38 Swedish schools: 500 CFU/M 3 and 4, 500 CFU/m 3 (Smedje et al, 1996, 1997) Carpeted 1900 CFU/g dust vs. bare floors 950 CFU/g(p=. 0. 002) Most prevalent genera: Penicillium, Fusarium, Alternaria and Cladosporium (Gravesen et al, 1986)

Reference History Phy. Exam Affected Bldg. Spec. mold(s) implicated Croft et al 1985 5 persons: cold, flu, sore throats, diarrhea, headaches, fatigue, dermatitis, alopecia, malaise Repeatedly Neg. Home Stachybotrys species Brunekreef et al 1989 22 6273 US children (respiratory questionnaire) no control subjects Not done Homes Total molds, spores Platt et al 1989 25 1169 UK children in 597 households: excess bad nerves, aching joints, nausea and vomiting, backache, blocked nose, fainting spells, constipation, breathlessness Not done Homes measured Dampness or mold Total molds, spores Strachan et al 1990 24 Children with asthma wheezed more in homes with higher mold counts Yes, Spirometry Homes mold quantitation Total molds, spores Li & Hsu 1996 23 1370 Children : questionnaire for selfreport of dampness, mold & respiratory symptoms Not done Homes Total molds, spores Cooley et al 1998 20 622 Adult workers at 48 schools with indoor air quality complaints: no control subjects Not done Schools Penicillium species, strachybotrys species Johanning et al, 1999 21 Descriptive study: 22 children and 125 adults with multiple symptoms Done, not reported Homes (no data on fungal exposure strachybotrys species Santilli & Rockwell 2003 27 Rhinitis questionnaire: 85 students & teachers Not done 2 schools Total molds, spores 16 Terr. A. JAll Clin Imm 2004; 113: 221

Cooley J. Occupational Environ Med 1998: 55: 579 -584

Mold in Schools: Studies n n n Allergy in form of RAST to molds and (+) PST particularly Aspergillus associated with Ig. G antibodies to molds found in mold damaged building. No association was found Ig. G to mold and exposure in school. (Taskinen. TMetal. Allergy: 2002. 57(1)9 -16) Sinusitis in teachers associated with elevated mold specific Ig. G to multiple fungi including Aspergillus and Stachybotrys with decrease in Ig. G on 2 year followup with sinusitis/bronchitis. (Patovirtaetal. IJOMEH 2003; 16(3) Association between elevated Ig. G to Penicillium notatum and E. amstelodami and moisture damage in school. (Hyvarinen. A. Arch. En. Hlth 2003; 58(5): 275 -83) Mold in floor dust had no positive association with building related symptom. but 5/8 symptoms secondary to asthma , hayfever, recent airway infection or psychosocial factors. (Meyers: Indoor. Air 2004; 14: 65 -72) Childrens’ perception of symptoms increased after publicized that exposure to mold in schools related to cough, wheezing and joint pains. (Handal Get al Indoor Air 2004; 14: 87 -91 )

Mold in schools n n n 33% U. S. public schools need extensive repair(6/96 GAO) Two Connecticut public schools (Fairfield County) tested using multiple air quality testing methods with standard for healthy indoor environment for total mold spore counts 1, 000 spores/m 3 In both schools counts were elevated (1 st : 6000 -50, 000 sp/m 3, 2 nd 2 -9000 sp/m 3) with associated allergic symptoms. Both were remediated. The first school was demolished and rebuilt. Santilli et al : Ann Allergy Asthma Imm. 2003; 90: 203 -208

Santilli J et al. Fungal contamination of elementary schools: a new environmental hazard. Ann Allergy Asthma Imm 2003; 90: 203 -8.

Santilli J etal. Fungal contamination of elementary schools: a new environmental hazard. Ann Allergy Asthma Immunol 2003; 90: 203 -8

Fungi: Environmental assessment n n n Air sampling: examples Standard > 1000 sp/ m 3, 100 cfu/m 3, 75% (I-O). 1. Viable: culture plates colony counts 2. Nonviable: spores (spores/m 3) 3. Surface sample (swipe) Qualitative only Multiple samples: agitation/indoor /outdoor Good labs certified n n n www. aiha. org, www. aaaai. org, . www. paaa. org Terr A. The role of mold in disease and non disease, Amer, Acad All Asthma Imm Meeting San Francisco, California 3/04

Table 1 Turner Environmental’s Testing of Mckinley Elementary School Revealed Severe Mold Contamination of the Wall Cavities and Rugs Carpet Samplings Colony Forming Units/Gm Room 117 108, 500, 000 Room 118 20, 120, 000 Room 221 1, 970, 000 Wall Cavity Samplings Mold Spores/m 3 Room 107 156, 666 Room 117 106, 667 Room 121 120, 000 Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003; 90: 203 -208

Figure 4 Results of ASHA testing indoor air quality at Mckinley Elementary School Fig 5 Results of Turner Environmental testing indoor air quality at Mckinley Elementary School Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003; 90: 203 -208

Fungal Contamination of Elementary schools: a new environmental hazard, Santilli J, Rockwell W; Ann Allergy Asthma Immunol 2003; 90: 203 -208

vomiting Fatigue Runny Nose Coughing Headaches Symptoms Flu symptoms Congestion Irritated eyes New or aggravated Asthma Some less common symptoms: fever, vomiting, nausea, nosebleeds, dizziness, memory loss, diarrhea and changes in behavior Mycotoxin related symptoms Muilenberg. ML. Toxigenic fungi. Current Views in All Imm V; XXXII I/04. Med. Coll. Geo.

Amr S et al. Environmental Allergens and Asthma in Urban Elementary Schools. Ann Allergy Asthma Immunol 2003; 90: 34 -40

Mold in schools v v v Skin prick test findings from moisture and mold damaged schools: Mold allergy in a 3 year follow up disappeared in 2 children and developed in 5. 5/6 of children with reactions >/= 3 mm to molds had (+) response to other allergens 5 children had clinical atopy/2 asthma All six children had been exposed to moisture and dampness in the school buildings Most reactions to molds in child >14 y with multiple SPT reactions to common allergens but no association with asthma Immonen Jet al Pediatric Allergy and Imm. : 2001; 12(2): 87 -94

Toxigenic Fungi M. L. Muilenberg n n n n Livestock exposures to mycotoxins Human food and mycotoxins The toxigenic fungi and their mycotoxins n Alternaria, Aspergillus, Fusarium, Penicillium, Stachybotrys Respiratory exposures to mycotoxins Sampling and exposure Recommendations Summary Muilenberg M. Toxigenicfungi. Current Views in Allergy Immunology. 2004; Volume. XXXII. Program 4(January)Medical College of Georgia.

Mycotoxins (Etzel RA, JAMA 2002) Aflatoxins Aspergillus Flavus Corn GI/ Neuro Clavine alkaloids Claviceps Fusiformis Millet GI/ Drow. Ergometrine C. Purpurea (St. A Fire) Barley GI/ N/ Gang Fumonisms Fusarium (horse, swine) Corn N/P/Death Cyclopiazonic Aspergillus Millet GI/ Giddy Ochratoxin Penicillum / Asp Grains Renal T 2 Toxin Fusarium (cattle) Corn Abortion Trichothecenes Fusarium / Asp Wheat GI Tremorgens Asp/ Pen/ Muc/ Rh/ Cep Grass/ Alf GI/ N Slaframine Rhizo (horse, cattle, sheep) Gr/ Wh GI/ N Etzel RA. Mycotoxins. Jnl. Amer. Med Ass. 2002; 287(4): 425 -7.

Human Stachybotryotoxicosis n n n By ingestion: 1930’s in Siberia horses fed moldy grain developed agranulocytosis, GI hemorrhage and ulceration similar reports in sheep, other animals and farmers. 1942 USSR Academy of Sciences (VG Drobotko) By inhalation never proven in humans would require massive doses seen in agricultural or remediation settings (x 10 to 6 th power or more spores/mm 3) 2. 1 x 106 spores / m 3 for infant 15. 3 x 106 spores /m 3 for an adult. Acute interstitial pulmonary hemosiderosis (AIPH) (Terr A. Mold in disease and non-disease AAAAI 3/2004)(Muilenberg M Current Views Allergy Immunology 2004; Volume XXXII. Prog 4. Med. Coll. Geo.

Summary continued n CDC investigation 1999 n Conclusion: n n Human diseases from mold: n n n A possible association between acute pulmonary hemorrhage…and (mold) exposure …was not proven (CDC. Report of working group on pulm. hemorrhage and hemosiderosis, CDC and Prevention, 1999) Specific molds produce infectious or allergic disease Toxic conditions from inhalation of mold spores is unproven. (Terr AThe role of mold in disease and nondisease. AAAAI 3/04) Current scientific evidence does not support…that human health has been adversely affected by inhaled mycotoxins in home, school or office environments. ACOEM JOEM 2003; 45(5): 470 -78

DIAGNOSIS & REMEDIATION NHLBI: v Goals for Healthy School Environment v Keep temperature and humidity appropriate v Maintain HVAC systems v Dry up damp and wet areas within 12 days v Minimize exposure to triggers: smoke, chemical vapors, chalk dust, mold, fumes and animals. v

Approach for Patient o o Log of walk through school : check for mold or water damage, stagnant water, inadequate ventilation, air intake grills Check ceilings, tiles, walls looking for water stains including inside closets, boxes and behind furniture Damp musty smell or visible colored deposits green, brown, yellow or black should be taken care of immediately to prevent spreading Tell your doctor (Healthy Schools Network, Inc: Albany, NY www. healthyschools. org)

Evaluation of Building related illness by specialist Ø Ø Ø Ø Ø Comprehensive history: nature of symptoms, home, work environment, medical and family history. Physical exam: signs of systemic fungal, Tb and pneumocystis pneumonia Atopy: skin and serologic testing and PFT pre and post bronchodilator Chest x-ray /CT of chest Supportive testing serologic Ig to fungi, for humoral and cell med immunity and pneumonitis Environmental assess: walk through and sample measurement of vacuumed dust sample and water damaged areas by prof. hygienist Measurement of total symptom scores inside and outside Pre-bronchodilator and post-bronchodilator measurement of spirometry inside and outside home or workplace every 2 -4 hrs while awake and correlate with environmental exposure measurement. Tools for schools EPA (Environmental Protection Agency) OSHA (Occupational Safety and Health Administration) Chapman et al Annals Allergy, Asthma, Immunol 2003; 91: 222 -232

TABLE : METHODS FOR IDENTIFICATION OF INDOOR FUNGAL EXPOSURE Method Advantage Disadvantage Implications Visual id air sample Rapid for airborne exposure sensitive No species, laborious Inhaled species associate disease Culture Identify species assay for mycotoxins Laborious must grow Inhaled spores cause on media not disease sensitive Questionaire Inexpensive Not specific or validated Allergen Immunoassay Very sensitive specific for genera Monoclonal too specific Measures allergic potential Mycotoxins Toxic potental of exposure Assay difficult to reproduce: EIA Chromotography Organ toxicity Ergosterol Fungal Mass Not useful for taxa None EPSs To identify genera B(1 -3) glucan Fungal Mass Non-fungal sources affect Inflammation VOCs(Volatile organic compounds) PCR need standards Specific for taxa Non-fungal sources affect Irritant None BUSH R, PORTNOY J. The role and abatement of fungal allergens in allergic disease. JALLERGY CLIN IMMUNOL 2001; 107: S 430 -440

Results Report n n n Scope of work Site physical description Review of mechanical systems: HVAC, etc Sample location and circumstances Summary analytic results and recommendations including walk-through Analytic reports: IAQ measurements with spore counts by genus indoor and outdoor ratio, rooms sampled, bulk and surface samples , vacuum dust samples in CFU/gm or m 2, instruments used, lab reports (Portnoy J Allergy Clin Imm. 2004; 113(2): 190 -198

Assessment and remediation of indoor fungi Prompt remediation of contaminated material and infrastructure repair. Prevent contamination through proper building, heating, ventilation, air conditioning (HVAC) maintenance and repair of water damage. (Tools) More research needed to link health outcomes and mycotoxins. Env assessment: visual inspection HVAC, ceilings, gypsum wallboard, paper and cellulose containing surfaces. Indoor and outdoor comparisons (no standard or human dose response) range upward from 100 CFU/m 3. School closures and rebuilding. Remediation of water damage or condensation immediately (RH<60%) control mold by 4 different levels 10 sq ft to 100 sq ft and HVAC (NYC Dept Hlth) (USEPA, OSHA, Amer Conf Gov Ind. Hygenists) see WWW Concern little science to support public reaction (“black box”). Chapman et al. Toxic mold: phantom risk vs science. Annals Allergy Asthma , Immunol 91: 222 -232

Checklist for mold remediation ü ü ü Communicate with building occupants at all times with designated person Plan remediation: trained remediation personnel, proper containment equipment and personal protective equipment, cleanup mold items and drying non-moldy materials within 48 hours. Remediation moisture and mold problems: Fix moisture problems including maintenance and/or repair Eliminate porous material infested with mold that can’t be cleaned. EPA. Mold remediation in schools and commercial buildings. EPA 402 -K-01 -001. 3/01.

Conclusions n n n Rigorous prospective studies linking exposure to mold in water damaged school environments and subsequent human disease need to be done. In the interim if after careful inspection more extensive water damage (>10 sq ft) is suggested especially with symptomatic personnel, then professional investigation by OSHA and industrial hygienist with micro and bulk sampling as well as appropriate air sampling indoor and outdoor is recommended. Remediation to correct existing and prevent further water damage should then be done by professionals.

Resource list: EPA n n IAQ (Indoor air quality) in schools www. epa. gov/iaq/schools/index. html Mold remediation in schools www. epa. gov/iaq/pubs/molds. html Indoor air quality(IAQ)home page www. epa. gov/iaq EPA IAQ Clearinghouse iaqinfo@aol. com

Mold Remediation Labs Aerobiology Instruction & Research 465 Washington St. , #1 Brookline, MA 02446 Aerobiology Lab Assoc. , Inc. 11800 Sunrise Valley Dr, Suite 1250 Reston, VA 20191 Environmental Microbiology Lab 10636 Scripps Summit Ct. , Ste. 103 San Diego, CA 92131 P&K/Aerotech Microbiology Services, Inc. 1936 Olney Ave. Cherry Hill, NJ 08003 (RT-PCR; culture, spore ID) Environmental Testing and Technology, Inc. 4176 Mt. Hukee Ave. San Diego, CA 92117 Air Quality Sciences, Inc. Atlanta, GA (770)933 -0638 EMSL Analytical, Inc. N. Miami Beach, FL (800)220 -3675

References 1. 2. 3. 4. Dales RE, Cakmak S, Burnett RT et al. Influence of ambient fungal spores on emergency visits for asthma to a regional children’s hospital. Am J Respir Crit Care Med. 2000; 162(6): 2087 -90 Platts-Mills TAE Solomon W. Aerobiology and inhalant allergens. Chapter 19. Allergy: Principlesand. Practice. ed E Middleton, CE Reed, EF Ellis, NFAtkinson et al. Fourth edition Volume 1 : Mosby St Louis, Missouri, 1993: 469 -528 Belkin L. Haunted by mold. NY Times Magazine August 12, 2001 Late ed. Section 6, Column 1, p 28(16 pages) Webster’s New World Dictionary. Copyright 1994, Simon and Schuster , Macmillan New York, New York p 873.

References 5. Biology 5 thed NACampbell, JB Reece , LG Mitchell. Chapter 31. Fungi. P 574 -588. Addison Wesley Longman, Inc 1999 Menlo Park , California 6. Terr A. Role of mold in disease and nondisease. AAAAI meeting San. Franciso 3/04. 7. Chapman JA, Terr. AI, Jacobs et al. Toxic mold: phantom risk vs science. Annals Allergy 2003; 91: 222 -232

References 8. Burge HA Fungi: Toxi killers or unavoidable nuisance. Annals Allergy, Asthma, Immunol 2001: 87(Suppl) 52 -56. 9. Burge HA. Bioaerosols and the scientific method. Ann Allergy Asthma Immunol 2003: 91: 217 -219 10. Healthy Schools Network. Albany, NY www. healthyschools. org 11. Bush RK , Prochnau JJ. Alternaria-induced asthma. J Allergy Clin Immunol 2004; 113: 227 -34.

References continued 12. Dishop ML. Maintaining environmental cleanliness in school. Supplement in the Jnl School Nursing. 2002(October): 23 -26 13. Morris, AB. Ed. (1997). Does design make a difference: A conference of the AIA Committee on Architecture for Education. Scottsdale: American Institute of Architects. 14. Meklin T, Hyvarinen A, Toivola M, etal. Effect of building frame and moisture damage on microbiological indoor air quality in school buildings. AIHA J; a J Sci Occ Env Hlth Safety. 2003; 64(1): 108 -116 15. Terr AI. Are indoor molds causing a new disease? J Allergy Clin Immunol 2004; 113: 221 -6.

References continued 21. 22. 23. 24. 25. Cuijpers CE, Swaen GM, Wessling G, et al. Adverse effects of the indoor environment on respiratory health in primary school children. Environ. Res 1995; 68; 11 -23. Garrett MH , Rayment PR, Hooper MA et al. Indoor airborne fungi, spores, house dampness and associations with environmental factorsand respiratory health in children. Clin Exp. Allergy. 1998: 28; 459 -467. Koskinen OM, Husman TM, Hyvarinen AM. Respiratory symptoms and infections among children in a day –care-center with mold problems. Indoor Air-Int J Indoor Air Quality Climate. 1995; 5: 3 -9 Kosknen OM, Husman TM, Hyvarinen AM, et al. Two moldy daycare centers : a follow-up study of respiratory symptoms and infections. Indoor Air-Int J Indoor Air Quality Climate. 1997; 7: 262 -268. Douwes J. Respiratory health effects of indoor microbial exposure. A contribution to the development of exposure assessment methods. Thesis, Wageningen. 1998: 1 -171.

References 26. Meyer HW, Wurtz H, Suadicani P, et al. Molds in floor dust and building related symptoms in adolescent school children. Indoor Air 2003; 14: 65 -72 27. Handal G, Leiner MA, Cabrera M etal. Children symptoms before and after knowing about an indoor fungal contamination. Indoor Air 2004; 14: 87 -91. 28. Santilli J, Rockwell W. Fungal contamination of elementary schools : a new environmental hazard: Ann Allergy Asthma Immunol 2003; 90: 203 -8. 29. O’Connor GT, et al Airborne fungi in the homes of children with asthma in low income urban communities: The Inner City Asthma. J Allergy Clin Innumol 2004: 114: 599: 606 30. Daisy JM, Angell WJ, Apte MG. Indoor air quality, ventilation, and health symptoms in school : An analysis of existing information. Indoor Air 2003; 13(1): 53 -64 31. Amr S, Bollinger. MS, Meyers M, et al. Environmental allergy and asthma in urban elementary schools. Ann Allergy Asthma Immunol 2003; 90(1): 34 -40. 32. Immonen J, Meklin. T, Taskinen T, et al. Skin prick test findings in students from moisture and mould –damaged schools: a 3 year follow up study. Pediatric Allergy and Immunology. 2001; 12(2): 87 -94. 33. Savilahti R, Utti J , Roto P, et al. Increased prevalence of atopy among children exposed to mold in a school building. Allergy 2001; 56(2): 175 -9. 34. Muilenberg ML. Toxigenic fungi. Current Views in Allergy Immunology. Volume XXXII: 1/04. Medical. College Georgia

References continued 35. Etzel RA. Mycotoxins. JAMA 2002; 287(4): 425 -7. 4 36. Etzel RA, Balk SJ, Bearer C Fetal. Committee on Environmental Health 1997 -8. American Academy of Pediatrics. Toxic effects of indoor molds. Pediatrics 1998; 4: 712 -713. 37. Montana E , Etzel RA , Allan T, et al. Environmental risk factors associated with pediatric idiopathic pulmonary hemorrhage and hemosiderosis in a Cleveland community. Pediatrics 1997; 99(1): 117 -24. 38. CDC. Reportof the CDC Working Group on Pulmonary Hemorrhage and Hemosiderosis. Atlant, Georgia: CDCand Prevention 1999. 39. CDC. Notice to readers. Availablity of case definition for acute idiopathic pulmonary hemorrhage in infants. Atlanta, Georgia : Center for Disease Control and Prevention; 2001; 50(23): 494 -5. 40. Kuhn DM, Ghannoun MA. Indoor mold, toxigenic fungi and Stachybotrys chartarum: Infectious disease perspective. Clinical Microbiology Reviews 2003; 16(1): 144 -72. 41. Bennett JW , Klich M. Mycotoxins Clinical Microbiology Reviews 2003; 16(3): 497 -516. 42. Robbins CA, Swenson LJ, Nealley. ML et al Health effects of mycotoxins in indoor air : a critical review. Applied Occupational and Environmental Hygiene 2000; 15(10): 773 -84. 43. Hardin BD, Kelman BJ, Saxon A. Adverse human health effects associated with molds in the indoor environment (statement). Journal Occupational and Environmental Medicine 2003: 45(5): 470 -78

References continued 44. Bush RK, Portnoy J. The role of abatement of fungal allergens in. allergic diseases. JAllergy Clin Immunol 2001; 107: S 430 -40 45. Meklin T, Haugland RA, Reponen. T, et al. Quantitative PCR analysis of house dust can reveal abnormal mold conditions. J Environ. Monit 2004; 6(7): 615 -620. 46. Kauffman HF, Van der Heide S. Exposure , sensitization , and mechanisms of fungus-induced asthma. Current Allergy and Asthma Reports 2003; 3: 430 -437. 47. Heibling A, Reimers A. Immunotherapy in fungal allergy. Current Allergy and Asthma Reports 2003; 90: 34 -40. 48. Eggleston P. Environmental control for fungal allergen exposure. Current Allergy and Asthma Reports 2003; 3(5): 426 -9. 49. EPA. Mold remediation in schools and commercial buildings. EPA 402 -K-001 March 2001 USEPA