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Wood Decaying Fungi |
| Revised April 2001 Executive Summary On May 7, 1993 and recently revised in April 2000, the New York City Department of Health (DOH), the New York City Human Resources Administration (HRA), and the Mt. Sinai Occupational Health Clinic convened an expert panel on Stachybotrys atra in indoor environments. The purpose of the panel was to develop policies for medical and environmental evaluation and intervention to address Stachybotrys atra (now known as Stachybotrys chartarum (SC)) contamination. The original guidelines were developed because of mold growth problems in several New York City buildings in the early 1990's. This document revises and expands the original guidelines to include all fungi (mold). It is based both on a review of the literature regarding fungi and on comments obtained by a review panel consisting of experts in the fields of microbiology and health sciences. It is intended for use by building engineers and management, but is available for general distribution to anyone concerned about fungal contamination, such as environmental consultants, health professionals, or the general public. We are expanding the guidelines to be inclusive of all fungi for several reasons: Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium, Trichoderma, and Memnoniella) in addition to SC can produce potent mycotoxins, some of which are identical to compounds produced by SC. Mycotoxins are fungal metabolites that have been identified as toxic agents. For this reason, SC cannot be treated as uniquely toxic in indoor environments.
There have been reports linking health effects in office workers to offices contaminated with moldy surfaces and in residents of homes contaminated with fungal growth. Symptoms, such as fatigue, respiratory ailments, and eye irritation were typically observed in these cases. Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, fungal contaminants and other bioaerosols, and water-damaged homes), and currently its association with SC is unproven. The focus of this guidance document addresses mold contamination of building components (walls, ventilation systems, support beams, etc.) that are chronically moist or water damaged. Occupants should address common household sources of mold, such as mold found in bathroom tubs or between tiles with household cleaners. Moldy food (e.g., breads, fruits, etc.) should be discarded. Building materials supporting fungal growth must be remediated as rapidly as possible in order to ensure a healthy environment. Repair of the defects that led to water accumulation (or elevated humidity) should be conducted in conjunction with or prior to fungal remediation. Specific methods of assessing and remediating fungal contamination should be based on the extent of visible contamination and underlying damage. The simplest and most expedient remediation that is reasonable, and properly and safely removes fungal contamination, should be used. Remediation and assessment methods are described in this document. The use of respiratory protection, gloves, and eye protection is recommended. Extensive contamination, particularly if heating, ventilating, air conditioning (HVAC) systems or large occupied spaces are involved, should be assessed by an experienced health and safety professional and remediated by personnel with training and experience handling environmentally contaminated materials. Lesser areas of contamination can usually be assessed and remediated by building maintenance personnel. In order to prevent contamination from recurring, underlying defects causing moisture buildup and water damage must be addressed. Effective communication with building occupants is an essential component of all remedial efforts. Fungi in buildings may cause or exacerbate symptoms of allergies (such as wheezing, chest tightness, shortness of breath, nasal congestion, and eye irritation), especially in persons who have a history of allergic diseases (such as asthma and rhinitis). Individuals with persistent health problems that appear to be related to fungi or other bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Decisions about removing individuals from an affected area must be based on the results of such medical evaluation, and be made on a case-by-case basis. Except in cases of widespread fungal contamination that are linked to illnesses throughout a building, building-wide evacuation is not indicated. In summary, prompt remediation of contaminated material and infrastructure repair is the primary response to fungal contamination in buildings. Emphasis should be placed on preventing contamination through proper building and HVAC system maintenance and prompt repair of water damage. This document is not a legal mandate and should be used as a guideline. Currently there are no United States Federal, New York State, or New York City regulations for evaluating potential health effects of fungal contamination and remediation. These guidelines are subject to change as more information regarding fungal contaminants becomes available.
On May 7, 1993, the New York City Department of Health (DOH), the New York City Human Resources Administration (HRA), and the Mt. Sinai Occupational Health Clinic convened an expert panel on Stachybotrys atra in Indoor Environments. The purpose of the panel was to develop policies for medical and environmental evaluation and intervention to address Stachybotrys atra (now known as Stachybotrys chartarum (SC)) contamination. The original guidelines were developed because of mold growth problems in several New York City buildings in the early 1990's. This document revises and expands the original guidelines to include all fungi (mold). It is based both on a review of the literature regarding fungi and on comments obtained by a review panel consisting of experts in the fields of microbiology and health sciences. It is intended for use by building engineers and management, but is available for general distribution to anyone concerned about fungal contamination, such as environmental consultants, health professionals, or the general public. This document contains a discussion of potential health effects; medical evaluations; environmental assessments; protocols for remediation; and a discussion of risk communication strategy. The guidelines are divided into four sections: 1. Health Issues; 2. Environmental Assessment; 3. Remediation; and 4. Hazard Communication. We are expanding the guidelines to be inclusive of all fungi for several reasons: Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium, Trichoderma, and Memnoniella) in addition to SC can produce potent mycotoxins, some of which are identical to compounds produced by SC.1, 2, 3, 4 Mycotoxins are fungal metabolites that have been identified as toxic agents. For this reason, SC cannot be treated as uniquely toxic in indoor environments.
There have been reports linking health effects in office workers to offices contaminated with moldy surfaces and in residents of homes contaminated with fungal growth.12, 16, 17, 18, 19, 20 Symptoms, such as fatigue, respiratory ailments, and eye irritation were typically observed in these cases. Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, other microbial contaminants, and water-damaged homes), and currently its association with SC is unproven.21, 22, 23 The focus of this guidance document addresses mold contamination of building components (walls, ventilation systems, support beams, etc.) that are chronically moist or water damaged. Occupants should address common household sources of mold, such as mold found in bathroom tubs or between tiles with household cleaners. Moldy food (e.g., breads, fruits, etc.) should be discarded. This document is not a legal mandate and should be used as a guideline. Currently there are no United States Federal, New York State, or New York City regulations for evaluating potential health effects of fungal contamination and remediation. These guidelines are subject to change as more information regarding fungal contaminants becomes available.
1.1 Health Effects There are only a limited number of documented cases of health problems from indoor exposure to fungi. The intensity of exposure and health effects seen in studies of fungal exposure in the indoor environment was typically much less severe than those that were experienced by agricultural workers but were of a long-term duration.5-10, 12, 14, 16-20, 25-27 Illnesses can result from both high level, short-term exposures and lower level, long-term exposures. The most common symptoms reported from exposures in indoor environments are runny nose, eye irritation, cough, congestion, aggravation of asthma, headache, and fatigue.11, 12, 16-20 The presence of fungi on building materials as identified by a visual assessment or by bulk/surface sampling results does not necessitate that people will be exposed or exhibit health effects. In order for humans to be exposed indoors, fungal spores, fragments, or metabolites must be released into the air and inhaled, physically contacted (dermal exposure), or ingested. Whether or not symptoms develop in people exposed to fungi depends on the nature of the fungal material (e.g., allergenic, toxic, or infectious), the amount of exposure, and the susceptibility of exposed persons. Susceptibility varies with the genetic predisposition (e.g., allergic reactions do not always occur in all individuals), age, state of health, and concurrent exposures. For these reasons, and because measurements of exposure are not standardized and biological markers of exposure to fungi are largely unknown, it is not possible to determine "safe" or "unsafe" levels of exposure for people in general. 1.1.1 Immunologic Effects Immunological reactions include asthma, HP, and allergic rhinitis. Contact with fungi may also lead to dermatitis. It is thought that these conditions are caused by an immune response to fungal agents. The most common symptoms associated with allergic reactions are runny nose, eye irritation, cough, congestion, and aggravation of asthma.11, 12 HP may occur after repeated exposures to an allergen and can result in permanent lung damage. HP has typically been associated with repeated heavy exposures in agricultural settings but has also been reported in office settings.25, 26, 27 Exposure to fungi through renovation work may also lead to initiation or exacerbation of allergic or respiratory symptoms. 1.1.2 Toxic Effects A wide variety of symptoms have been attributed to the toxic effects of fungi. Symptoms, such as fatigue, nausea, and headaches, and respiratory and eye irritation have been reported. Some of the symptoms related to fungal exposure are non-specific, such as discomfort, inability to concentrate, and fatigue.11, 12, 16-20 Severe illnesses such as ODTS and pulmonary hemosiderosis have also been attributed to fungal exposures.5-10, 21, 22 ODTS describes the abrupt onset of fever, flu-like symptoms, and respiratory symptoms in the hours following a single, heavy exposure to dust containing organic material including fungi. It differs from HP in that it is not an immune-mediated disease and does not require repeated exposures to the same causative agent. ODTS may be caused by a variety of biological agents including common species of fungi (e.g., species of Aspergillus and Penicillium). ODTS has been documented in farm workers handling contaminated material but is also of concern to workers performing renovation work on building materials contaminated with fungi.5-10 Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, fungal contaminants and other bioaerosols, and water-damaged homes), and currently its association with SC is unproven.21, 22, 23 1.1.3 Infectious Disease Only a small group of fungi have been associated with infectious disease. Aspergillosis is an infectious disease that can occur in immunosuppressed persons. Health effects in this population can be severe. Several species of Aspergillus are known to cause Aspergillosis. The most common is Aspergillus fumigatus. Exposure to this common mold, even to high concentrations, is unlikely to cause infection in a healthy person.11, 24 Exposure to fungi associated with bird and bat droppings (e.g., Histoplasma capsulatum and Cryptococcus neoformans) can lead to health effects, usually transient flu-like illnesses, in healthy individuals. Severe health effects are primarily encountered in immunocompromised persons.24, 28, 29 1.2 Medical Evaluation Individuals with persistent health problems that appear to be related to fungi or other bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Infants (less than 12 months old) who are experiencing non-traumatic nosebleeds or are residing in dwellings with damp or moldy conditions and are experiencing breathing difficulties should receive a medical evaluation to screen for alveolar hemorrhage. Following this evaluation, infants who are suspected of having alveolar hemorrhaging should be referred to a pediatric pulmonologist. Infants diagnosed with pulmonary hemosiderosis and/or pulmonary hemorrhaging should not be returned to dwellings until remediation and air testing are completed. Clinical tests that can determine the source, place, or time of exposure to fungi or their products are not currently available. Antibodies developed by exposed persons to fungal agents can only document that exposure has occurred. Since exposure to fungi routinely occurs in both outdoor and indoor environments this information is of limited value. 1.3 Medical Relocation Infants (less than 12 months old), persons recovering from recent surgery, or people with immune suppression, asthma, hypersensitivity pneumonitis, severe allergies, sinusitis, or other chronic inflammatory lung diseases may be at greater risk for developing health problems associated with certain fungi. Such persons should be removed from the affected area during remediation (see Section 3, Remediation). Persons diagnosed with fungal related diseases should not be returned to the affected areas until remediation and air testing are completed. Except in cases of widespread fungal contamination
that are linked to illnesses throughout a building, a building-wide
evacuation is not indicated. A trained occupational/environmental
health practitioner should base decisions about medical removals
in the occupational setting on the results of a clinical assessment.
The presence of mold, water damage, or musty odors should be addressed immediately. In all instances, any source(s) of water must be stopped and the extent of water damaged determined. Water damaged materials should be dried and repaired. Mold damaged materials should be remediated in accordance with this document (see Section 3, Remediation). 2.1 Visual Inspection 2.2 Bulk/Surface Sampling Bulk or surface sampling is not required to undertake a remediation. Remediation (as described in Section 3, Remediation) of visually identified fungal contamination should proceed without further evaluation.
Air sampling for fungi should not be part of a routine assessment. This is because decisions about appropriate remediation strategies can usually be made on the basis of a visual inspection. In addition, air-sampling methods for some fungi are prone to false negative results and therefore cannot be used to definitively rule out contamination.
Microscopic identification of the spores/colonies requires considerable expertise. These services are not routinely available from commercial laboratories. Documented quality control in the laboratories used for analysis of the bulk/surface and air samples is necessary. The American Industrial Hygiene Association (AIHA) offers accreditation to microbial laboratories (Environmental Microbiology Laboratory Accreditation Program (EMLAP)). Accredited laboratories must participate in quarterly proficiency testing (Environmental Microbiology Proficiency Analytical Testing Program (EMPAT)). Evaluation of bulk/surface and air sampling data
should be performed by an experienced health professional. The presence
of few or trace amounts of fungal spores in bulk/surface sampling
should be considered background. Amounts greater than this or the
presence of fungal fragments (e.g., hyphae, and conidiophores) may
suggest fungal colonization, growth, and/or accumulation at or near
the sampled location.30 Air samples should be evaluated by means
of comparison (i.e., indoors to outdoors) and by fungal type (e.g.,
genera, and species). In general, the levels and types of fungi
found should be similar indoors (in non-problem buildings) as compared
to the outdoor air. Differences in the levels or types of fungi
found in air samples may indicate that moisture sources and resultant
fungal growth may be problematic. 3. Remediation In all situations, the underlying cause of water accumulation must be rectified or fungal growth will recur. Any initial water infiltration should be stopped and cleaned immediately. An immediate response (within 24 to 48 hours) and thorough clean up, drying, and/or removal of water damaged materials will prevent or limit mold growth. If the source of water is elevated humidity, relative humidity should be maintained at levels below 60% to inhibit mold growth.31 Emphasis should be on ensuring proper repairs of the building infrastructure, so that water damage and moisture buildup does not recur. Five different levels of abatement are described below. The size of the area impacted by fungal contamination primarily determines the type of remediation. The sizing levels below are based on professional judgment and practicality; currently there is not adequate data to relate the extent of contamination to frequency or severity of health effects. The goal of remediation is to remove or clean contaminated materials in a way that prevents the emission of fungi and dust contaminated with fungi from leaving a work area and entering an occupied or non-abatement area, while protecting the health of workers performing the abatement. The listed remediation methods were designed to achieve this goal, however, due to the general nature of these methods it is the responsibility of the people conducting remediation to ensure the methods enacted are adequate. The listed remediation methods are not meant to exclude other similarly effective methods. Any changes to the remediation methods listed in these guidelines, however, should be carefully considered prior to implementation. Non-porous (e.g., metals, glass, and hard plastics) and semi-porous (e.g., wood, and concrete) materials that are structurally sound and are visibly moldy can be cleaned and reused. Cleaning should be done using a detergent solution. Porous materials such as ceiling tiles and insulation, and wallboards with more than a small area of contamination should be removed and discarded. Porous materials (e.g., wallboard, and fabrics) that can be cleaned, can be reused, but should be discarded if possible. A professional restoration consultant should be contacted when restoring porous materials with more than a small area of fungal contamination. All materials to be reused should be dry and visibly free from mold. Routine inspections should be conducted to confirm the effectiveness of remediation work. The use of gaseous ozone or chlorine dioxide for remedial purposes is not recommended. Both compounds are highly toxic and contamination of occupied space may pose a health threat. Furthermore, the effectiveness of these treatments is unproven. For additional information on the use of biocides for remedial purposes, refer to the American Conference of Governmental Industrial Hygienists' document, "Bioaerosols: Assessment and Control." 3.1 Level I: Small Isolated Areas (10 sq. ft or less) - e.g., ceiling tiles, small areas on walls
Remediation can be conducted by regular building maintenance staff. Such persons should receive training on proper clean up methods, personal protection, and potential health hazards. This training can be performed as part of a program to comply with the requirements of the OSHA Hazard Communication Standard (29 CFR 1910.1200).
A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for the project. The following procedures at a minimum are recommended: Personnel trained in the handling of hazardous materials and equipped with respiratory protection, (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended. Gloves and eye protection should be worn.
3.4 Level IV: Extensive Contamination (greater than 100 contiguous square feet in an area) A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for the project. The following procedures are recommended: Personnel trained in the handling of hazardous materials equipped with:
3.5.1 A Small Isolated Area of Contamination (<10 square feet) in the HVAC System Remediation can be conducted by regular building maintenance staff. Such persons should receive training on proper clean up methods, personal protection, and potential health hazards. This training can be performed as part of a program to comply with the requirements of the OSHA Hazard Communication Standard (29 CFR 1910.1200).
A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for remediation projects involving more than a small isolated area in an HVAC system. The following procedures are recommended: Personnel trained in the handling of hazardous materials equipped with:
4. Hazard Communication When fungal growth requiring large-scale remediation is found, the building owner, management, and/or employer should notify occupants in the affected area(s) of its presence. Notification should include a description of the remedial measures to be taken and a timetable for completion. Group meetings held before and after remediation with full disclosure of plans and results can be an effective communication mechanism. Individuals with persistent health problems that appear to be related to bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Individuals seeking medical attention should be provided with a copy of all inspection results and interpretation to give to their medical practitioners.
In summary, the prompt remediation of contaminated material and infrastructure repair must be the primary response to fungal contamination in buildings. The simplest and most expedient remediation that properly and safely removes fungal growth from buildings should be used. In all situations, the underlying cause of water accumulation must be rectified or the fungal growth will recur. Emphasis should be placed on preventing contamination through proper building maintenance and prompt repair of water damaged areas. Widespread contamination poses much larger problems that must be addressed on a case-by-case basis in consultation with a health and safety specialist. Effective communication with building occupants is an essential component of all remedial efforts. Individuals with persistent health problems should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures.
Bata A, Harrach B, Kalman U, Kis-tamas A, Lasztity R. Macrocyclic Trichothecene Toxins Produced by Stachybotrys atra Strains Isolated in Middle Europe. Applied and Environmental Microbiology 1985; 49:678-81.
The New York City Department of Health would like to thank the following individuals and organizations for participating in the revision of these guidelines. Please note that these guidelines do not necessarily reflect the opinions of the participants nor their organizations. Name Company/Institution
Christopher D'Andrea, M.S. of the Environmental and Occupational Disease Epidemiology Unit, was the editor of this document. For further information regarding this document please contact the New York City Department of Health at (212) 788-4290. |
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