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Damp Indoor Spaces A N D H E A LT H Committee on Damp Indoor Spaces and Health Board on Health Promotion and Disease Prevention

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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001 NOTICE: The project that is the subject of this report was approved by the Govern- ing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineer- ing, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. This study was supported by Contract No. 200-2000-0629, TO #08 between the National Academy of Sciences and Centers for Disease Control and Prevention. Any opinions, findings, conclusions, or recommendations expressed in this publication are those of the author(s) and do not necessarily reflect the view of the organizations or agencies that provided support for this project. Library of Congress Cataloging-in-Publication Data Institute of Medicine (U.S.). Committee on Damp Indoor Spaces and Health. Damp indoor spaces and health / Committee on Damp Indoor Spaces and Health, Board on Health Promotion and Disease Prevention. p. ; cm. Includes bibliographical references and index. ISBN 0-309-09193-4 (hardback) 1. Indoor air pollution--Health aspects. 2. Dampness in buildings--Health aspects. 3. Air--Microbiology--Health aspects. 4. Housing and health. [DNLM: 1. Air Pollution, Indoor--adverse effects. 2. Air Pollution, Indoor-- prevention & control. 3. Air Microbiology. 4. Bacterial Toxins--adverse effects. 5. Mycotoxins--adverse effects. 6. Respiratory Tract Diseases--epidemiology. WA 754 I5538 2004] I. Title. RA577.5.I565 2004 613'.5--dc22 2004014365 Additional copies of this report are available for sale from the National Academies Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; call (800) 624- 6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http:// www.nap.edu. For more information about the Institute of Medicine, visit the IOM home page at: www.iom.edu. Copyright 2004 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The serpent adopted as a logotype by the Institute of Medicine is a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin. Cover: The images for the cover design were provided by Terry Brennan. The image at the center of the design is Stachybotrys chartarum and the border image is Cla- dosporium on paint.

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"Knowing is not enough; we must apply. Willing is not enough; we must do." --Goethe Adviser to the Nation to Improve Health

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The National Academy of Sciences is a private, nonprofit, self-perpetuating society of distinguished scholars engaged in scientific and engineering research, dedicated to the furtherance of science and technology and to their use for the general welfare. Upon the authority of the charter granted to it by the Congress in 1863, the Acad- emy has a mandate that requires it to advise the federal government on scientific and technical matters. Dr. Bruce M. Alberts is president of the National Academy of Sciences. The National Academy of Engineering was established in 1964, under the charter of the National Academy of Sciences, as a parallel organization of outstanding engi- neers. It is autonomous in its administration and in the selection of its members, sharing with the National Academy of Sciences the responsibility for advising the federal government. The National Academy of Engineering also sponsors engineer- ing programs aimed at meeting national needs, encourages education and research, and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president of the National Academy of Engineering. The Institute of Medicine was established in 1970 by the National Academy of Sci- ences to secure the services of eminent members of appropriate professions in the examination of policy matters pertaining to the health of the public. The Institute acts under the responsibility given to the National Academy of Sciences by its con- gressional charter to be an adviser to the federal government and, upon its own initiative, to identify issues of medical care, research, and education. Dr. Harvey V. Fineberg is president of the Institute of Medicine. The National Research Council was organized by the National Academy of Sciences in 1916 to associate the broad community of science and technology with the Academy's purposes of furthering knowledge and advising the federal government. Functioning in accordance with general policies determined by the Academy, the Council has become the principal operating agency of both the National Academy of Sciences and the National Academy of Engineering in providing services to the gov- ernment, the public, and the scientific and engineering communities. The Council is administered jointly by both Academies and the Institute of Medicine. Dr. Bruce M. Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National Research Council. www.national-academies.org

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COMMITTEE ON DAMP INDOOR SPACES AND HEALTH Noreen M. Clark, PhD (Chair), Dean, Marshall H. Becker Professor of Public Health, and Professor of Pediatrics, University of Michigan, Ann Arbor, Michigan Harriet M. Ammann, PhD, DABT, Senior Toxicologist, Air Quality Program, Washington State Department of Ecology, Olympia, Washington Bert Brunekreef, PhD, Professor of Environmental Epidemiology, Institute of Risk Assessment Sciences, University of Utrecht, The Netherlands Peyton Eggleston, MD, Professor of Pediatrics and Professor of Environment Health Sciences, Johns Hopkins University, Baltimore, Maryland William J. Fisk, MS, PE, Senior Staff Scientist and Department Head, Indoor Environment Department, Lawrence Berkeley National Laboratory, Berkeley, California Robert E. Fullilove, EdD, Associate Dean for Community and Minority Affairs, Columbia University School of Public Health, New York, New York Judith Guernsey, MSc, PhD, Associate Professor, Department of Community Health and Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada Aino Nevalainen, PhD, Head of Laboratory, Division of Environmental Health, National Public Health Institute (KTL), Kuopio, Finland Susanna G. Von Essen, MD, Professor of Pulmonary and Critical Care Medicine, University of Nebraska Medical Center at Omaha, Nebraska Consultants to the Committee Terry Brennan, MS, President, Camroden Associates, Inc., Westmoreland, New York Jeroen Douwes, PhD, Associate Director, Centre for Public Health Research, Massey University, Wellington, New Zealand Staff David A. Butler, PhD, Study Director Jennifer A. Cohen, Research Associate Joe A. Esparza, Senior Project Assistant Elizabeth J. Albrigo, Project Assistant Norman Grossblatt, Senior Editor Rose Marie Martinez, ScD, Director, Board on Health Promotion and Disease Prevention v

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Reviewers This report has been reviewed in draft form by persons chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the institution in making its published report as sound as possible and to ensure that the report meets institutional standards of objectivity, evidence, and responsiveness to the study charge. The review comments and draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following for their review of this report: Diane R. Gold, MD, MPH, Harvard Medical School and Harvard School of Public Health William B. Rose, MArch, School of Architecture, University of Illinois at Urbana-Champaign Jonathan M. Samet, MD, Bloomberg School of Public Health, Johns Hopkins University Richard J. Shaughnessy, PhD, Indoor Air Program, University of Tulsa Linda D. Stetzenbach, PhD, Harry Reid Center for Environmental Studies, University of Nevada, Las Vegas Mark J. Utell, MD, University of Rochester School of Medicine and Dentistry Although the reviewers listed above have provided many constructive comments and suggestions, they were not asked to endorse the conclusions or recommendations, nor did they see the final draft of the report before its release. The review of this report was overseen by Robert B. Wallace, MD, University of Iowa, and John C. Bailar III, MD, PhD, University of Chicago. Appointed by the National Research Council and Institute of Medicine, they were responsible for making certain that an independent examination of this report was carried out in accordance with institutional procedures and that all review comments were carefully considered. Responsibility for the final content of this report rests entirely with the authoring committee and the institution. vi

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Acknowledgments This report could not have been prepared without the guidance and ex- pertise of numerous persons. Although it is not possible to mention by name all those who contributed to the committee's work, the committee wants to express its gratitude to a number of them for their special contributions. Sincere thanks go to all the participants at the workshops convened on March 26, June 17, and October 8, 2002. The intent of the workshops was to gather information regarding issues related to damp indoor spaces, health effects attributed to microbial agents found indoors, and mold- and moisture-related research. The speakers, who are listed in Appendix A, gave generously of their time and expertise to help inform and guide the com- mittee's work. We are deeply indebted to two hard-working people--Terry Brennan and Jeroen Douwes--who served as consultants and made major contribu- tions to the content of this report. Special thanks are also extended to Harriet Burge, chair of the committee from its inception through October 2002, for her exceptional commitment and guidance during her tenure. The commit- tee also thanks Ulla Haverinen-Shaughnessy and Anne Hyvrinen, who per- mitted excerpting of text from their doctoral dissertations. Institute of Medi- cine staff members Michelle Catlin, Ben Hamlin, and Michael Schneider provided valuable input and help over the course of the study. The Commit- tee on Damp Indoor Spaces and Health, of course, takes final responsibility for all content in the report. The committee extends special thanks to the dedicated and hard-work- ing staff at the Institute of Medicine (IOM). The expertise and leadership of Rose Marie Martinez, director of the IOM Board on Health Promotion and Disease Prevention, helped to ensure that this report met the highest stan- dards of quality. Finally, the committee would like to thank the chair, Noreen Clark, for her outstanding work, leadership, and dedication to this project. vii

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viii

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Contents EXECUTIVE SUMMARY 1 Framework and Organization, 2 The Committee's Evaluation, 4 Reference, 16 1 BACKGROUND AND METHODOLOGIC CONSIDERATIONS 17 Intent and Goals of the Study, 17 Research Approach, 19 Evaluating the Epidemiologic Evidence, 21 Summarizing Conclusions Regarding Epidemiologic Evidence, 26 References, 27 2 DAMP BUILDINGS 29 Moisture Definitions, 30 Moisture Dynamics in Buildings--How Buildings Get Wet, 32 Prevalence, Severity, Location, and Duration of Building Dampness, 44 Risk Factors for Moisture Problems, 51 From Moisture to Microbial Growth, 54 Microorganisms Occurring in Indoor Spaces and on Building Materials, 56 Dampness-Related Problems Not Associated with Biologic Sources, 73 Summary, 75 Findings, Recommendations, and Research Needs, 76 References, 78 ix

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x CONTENTS 3 EXPOSURE ASSESSMENT 90 Introduction, 90 Definitions, 91 Sampling Strategies, 94 Assessing Microorganisms, 101 Assessing Microbial Constituents, 103 Assessing Bioallergens, 104 Indirect Exposure-Assessment Methods, 104 Concentrations in the Environment, 110 Evaluation of Exposure Data, 114 Findings, Recommendations, and Research Needs, 115 References, 116 4 TOXIC EFFECTS OF FUNGI AND BACTERIA 125 Considerations in Evaluating the Evidence, 126 Bioavailability and Route of Exposure, 126 Toxic Effects of Indoor Molds and Bacteria, 133 Findings, Recommendations, and Research Needs, 170 References, 171 5 HUMAN HEALTH EFFECTS ASSOCIATED WITH DAMP INDOOR ENVIRONMENTS 183 Introduction, 183 Evaluating Health Effects, 186 Respiratory Symptoms, 189 Respiratory Tract Disorders, 208 Other Health Complaints and Disorders, 243 Findings, Recommendations, and Research Needs, 253 References, 255 6 PREVENTION AND REMEDIATION OF DAMP INDOOR ENVIRONMENTS 270 Prevention, 270 Published Guidance for Mold Remediation, 271 Tasks Involved in Remediation, 284 Effects of Air and Surface Cleaning and Ventilation, 301 Findings, Recommendations, and Research Needs, 304 References, 306 7 THE PUBLIC HEALTH RESPONSE 311 Public Health and Housing, 312 Barriers to the Adoption of Dampness Prevention and Reduction Measures, 313

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CONTENTS xi Public Health Approaches to Damp Indoor Environments, 314 Findings, Recommendations, and Research Needs, 327 References, 329 APPENDIXES A WORKSHOP PRESENTATIONS AND SPEAKERS 333 B COMMITTEE, CONSULTANT, AND STAFF BIOGRAPHIES 336 INDEX 343

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