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Damp Indoor Spaces and Health (2004)
Board on Health Promotion and Disease Prevention (HPDP)
 Institute of Medicine (IOM)

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. "Index." Damp Indoor Spaces and Health. Washington, DC: The National Academies Press, 2004.

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Index A American Conference of Governmental Industrial Hygienists (ACGIH), Acetylglucosamine polymer fibrils, 68 102­103, 272, 274, 288, 301 ACGIH. See American Conference of guidance from, 296n Governmental Industrial Hygienists American Housing Survey, 316 Acremonium, 57 American Industrial Hygiene Association Actinomycetes, 145 (AIHA), 275, 284, 287, 296, Acute idiopathic pulmonary hemorrhage in 298 infants (AIPHI), 11, 241­242, 333 American Lung Association, 320n AFS. See Allergic fungal rhinosinusitis American Red Cross (ARC), 272 AIHA. See American Industrial Hygiene American Society for Testing and Materials Association (ASTM) methods, 294 AIPHI. See Acute idiopathic pulmonary American Society of Heating, Refrigerating hemorrhage in infants and Air-Conditioning Engineers Air filtration methods, for assessing (ASHRAE), 273 microorganisms, 101 ventilation standard, 297 Airborne bacteria, concentrations in indoor American Thoracic Society, 320n air, 111 Analytic bias, 22­23 Airborne fungal concentrations in confounding bias, 22 residences, in relation to building information bias, 22 dampness characteristics, 60­65 response bias, 23 Airflow obstruction, 211­212 reverse causality bias, 22 Allergens, isolated from fungi, 67. See also selection bias, 22 specific allergenic fungi Animals and animal cells Allergens of microbial origin, 67­68 experiments on mucous membrane Allergic fungal rhinosinusitis (AFS), 210 irritation and inflammation, 136 Alternaria, 57, 216, 225, 231, 236 respiratory effects in, 139­146 A. alternata, 55, 58, 211, 230, 316 ARC. See American Red Cross 343

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344 INDEX ASHRAE. See American Society of Heating, bacterial genera isolated from moldy Refrigerating and Air-Conditioning building materials, 66 Engineers on building materials, 59­65 Aspergillus, 57, 66, 70, 128, 134, 157, 161­ concentrations in the environment, 162, 189, 214, 216, 225, 235­236, 110­111, 112 247, 291 fungal genera found in infested A. alutaceus, 169 building materials, 64 A. clavatus, 162 fungi and other microorganisms A. flavus, 57, 71, 169 associated with dampness or mold A. fumigatus, 57, 71, 148­150, 163, 230 growth in buildings, 65 A. niger, 57­58 genera isolated from moldy building A. ochraceous, 145, 169 materials, 66 A. penicilloides, 57 in outdoor and indoor air, 56­59 A. versicolor, 54, 57, 71, 135, 154­ BALF. See Bronchoalveolar lavage fluid 155, 217 Barriers Assessment of epidemiologic evidence, 23­25 to the adoption of dampness Assessment of microorganisms, 101­103 prevention and reduction measures, culture-based methods, 101­102 313­314 exposure, 101­103 to prevention, 52­54 nonculture methods, 102­103 Beck Depression Inventory, 247 Assessment of public health approaches to BHR. See Bronchial hyperresponsiveness damp indoor environments, 315­ Bioaerosols: Assessment and Control, 317 274 Association. See Categories of association/ Bioavailability and route of exposure, 126­ evidence 133 Asthma, 215­231 experimental data, 130­133 in Clearing the Air, 219 inhaled spores deposited in respirable definition of disorder, 215 (alveolar) area of lung, 129 exacerbation of, 218­226 issues that affect bioavailability, 126­ other asthma issues, 216­217 130 role of sensitization, 215­216 some mycotoxins and the symptoms in asthmatic people and microorganisms that produce them, exposure to damp indoor 127 environment, 220­224 spore-deposition coefficients of mold Asthma development, 226­231 genera in indoor environments, and exposure to damp indoor 129 environments, 228­229 Biologic gradient (dose-response ASTM. See American Society for Testing relationship), 24 and Materials methods Biologic plausibility and coherence, 24 Atopic dermatitis, 245 Biomarkers, 109 Aureobasidium, 57 Boroscopes, 291 Bronchial hyperresponsiveness (BHR), 212 Bronchoalveolar lavage fluid (BALF), 136, B 144 Building materials, and microbial growth, (13)-glucans, concentrations in the 72­73 environment, 113­114 Buildings Bacillus spp., 59, 67, 71, 134 characteristics of, 51­52 Bacteria collecting histories of, 287­288 airborne fungal concentrations in as microbial habitats, 54­55 residences in relation to building dampness characteristics, 60­65

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INDEX 345 C CMHC. See Canadian Mortgage and Housing Corporation Calcium chloride test, 295 Collaboration, regarding public health California Occupational Safety and Health approaches to damp indoor Standards Board, 318 environments, 326­327 California Verbal Learning Test (CVLT), Collecting histories of building and 247 occupants, 287­288 Canadian Mortgage and Housing Colony-forming units (CFUs), 102 Corporation (CMHC), 272 Commercial buildings, in the United States, Cancers, 250­251 1 Candida, 134, 216 Committee on Curriculum Development in C. albicans, 148, 156, 194 Environmental Medicine, 325 Capillary electrophoresis, 104 Comparison, of seven mold-remediation Carcinogenesis, 166­170 guidance documents, 276­285 Carcinogenic effects, of mycotoxins, 167­ Components of microbial agents, 65­72 168 allergens of microbial origin, 67­68 Categories of association/evidence, 8, 26­27 gaps in building microbiology science, inadequate or insufficient evidence to 71 determine whether an association microbial volatile organic compounds, exists, 8­11, 27 69 limited or suggestive evidence of an spores and cells of bacteria, 67 association, 8­11, 27 spores and fragments of fungi, 66 sufficient evidence of a causal structural components of fungi and relationship, 8­11, 26 bacteria, 68­69 sufficient evidence of an association, toxic products of microbial secondary 8­11, 26 metabolism, 69­71 CDC. See Centers for Disease Control and Computed tomographic (CT) scans, 188 Prevention Concentrations in the environment, 110­ Cell-culture cytotoxicity testing, 104 114 Centers for Disease Control and Prevention airborne bacteria in indoor air, 111 (CDC), 2, 11, 15, 17, 240, 328­329 (13)-glucans, 113­114 CFUs. See Colony-forming units bacteria, 110­111 Chaetomium, 66, 71 bacterial types found in different Characterizing Moisture Damaged indoor environments, 112 Buildings--Environmental and endotoxins, 111­113 Biological Monitoring, 284 fungi, 110 Chronic obstructive pulmonary disease respiratory health related to indoor (COPD), 211, 213­215 endotoxin exposure, 112­113 Cladding, 34 Condensation and high humidity, 39­44 Cladosporium, 57, 134, 200, 216, 219, moisture in heating, ventilating, and 225, 230­231, 236 air-conditioning systems, 42­44 C. cladosporioides, 54, 58, 140­141, occupants as sources of moisture, 41­ 143­145 42 C. herbarum, 230 Confidence intervals, 21­22 C. sphaerospermum, 54, 58 Confounding, 23 Clearing the Air: Asthma and Indoor Air Confounding bias, 22 Exposures, 19, 56, 68, 184­185, Connecticut Public Act 03-220, 317, 319 215­216, 218­219, 226­227, 301, Conservation techniques, 298n 314, 321 Consistency, of association, 24 development of asthma in, 227 Construction moisture, 38

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346 INDEX Containment, establishing appropriate, fatigue and related symptoms and 295­297 exposure to, 248­249 Control of Moisture Problems Affecting nausea and related symptoms and Biological Indoor Air Quality, 274 exposure to, 246 COPD. See Chronic obstructive pulmonary skin problems and exposure to, 244 disease upper respiratory tract symptoms and Coprinus, 57 exposure to, 190­192 Corynebacterium, 59 wheeze and exposure to, 203­207 Cough, 194­201 Dampness definitions and associated and exposure to damp indoor environmental assessments, 4, 106­ environments, 195­199 108 CT. See Computed tomographic scans Dampness-related problems not associated Culture-based methods of assessing with biologic sources, 73­74 microorganisms, 101­102 Decontaminating or removing damaged air filtration methods, 101 materials as appropriate, 298­299 impactor methods, 101 Definitions of exposure assessment terms, liquid impinger methods, 101 91­94 Cunninghamella, 57 dose, 94 Curvularia, 57 exposure, 91­92 Cuyahoga County (Ohio) Department of exposure mechanisms, 92­93 Development, 323 Demonstration projects, public-health- CVLT. See California Verbal Learning Test oriented, 321­323 Dermal toxicity, 166 Development of asthma, 226­231 D in Clearing the Air, 227 and exposure to damp indoor Damp buildings, 4­5, 29­89 environment, 228­229 dampness-related problems not DMSO, 133 associated with biologic sources, Dose, 94 73­74 defined, 94 duration, 51 effective, 94 findings, 76­77 internal, 94 location, 50­51 Drechslera, 57 microorganisms occurring in indoor Duration, of dampness in buildings, 51 spaces and on building materials, Dyspnea, and exposure to damp indoor 56­73 environments, 208, 209 moisture definitions, 30­31 moisture dynamics and how buildings get wet, 32­44 E from moisture to microbial growth, 54­56 Economic and other incentives, in public prevalence, 44­49 health approaches to damp indoor recommendations, 77 environments, 319­320 research needs, 77­78 Eczema, 245 risk factors for moisture problems, 51­ Education, regarding public health 54 approaches to damp indoor severity, 49­50 environments, 324­326 Damp indoor environments Effective dose, 94 asthma development and exposure to, Electromagnetic fields (EMFs), 289 228­229 Eliminating moisture sources, and drying cough and exposure to, 195­199 the materials, 297­298 dyspnea and exposure to, 209

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INDEX 347 ELISA. See Enzyme-linked immunosorbent Evidence. See Categories of association/ assays evidence Emergency actions, to stop water intrusion, Experimental data, on bioavailability and taking if needed, 286 route of exposure, 130­133 EMFs. See Electromagnetic fields Experimental methods, to assess the Endotoxin units (EUs), 111 pulmonary effects of fungi, 334 Endotoxins, 68 Exposure, defined, 91­92 concentrations in the environment, Exposure assessment, 6­7, 90­124 111­113 assessing bioallergens, 104 Environmental tobacco smoke (ETS), 12, assessing microbial constituents, 103­ 184, 201, 214, 227, 229, 242­243 104 Enzyme-linked immunosorbent assays assessing microorganisms, 101­103 (ELISA), 104, 109 concentrations in the environment, Epidemiologic evidence, 17­28 110­114 and categories of association, 26­27 definitions, 91­94 considerations in assessing the strength evaluation of exposure data, of, 23­25 114­115 evaluating, 21­25 findings, 115­116 intent and goals of the study, 17­19 indirect exposure-assessment methods, research approach, 19­21 104­110 summarizing conclusions regarding, 26 recommendations, 115­116 Epioccum, 57, 225 research needs, 115­116 EPSs. See Extracellular polysaccharides sampling strategies, 94­101 Equilibrium relative humidity (ERH), 31, Exposure mechanisms, defined, 92­93 54, 72­73 Exposure surrogates, 91 test, 295 Extracellular polysaccharides (EPSs), 91 ERH. See Equilibrium relative humidity ETS. See Environmental tobacco smoke Eurotium spp., 54 F EUs. See Endotoxin units Evaluation Fans, HEPA-filtered, 299 Fatigue and related symptoms, 245­246 of the evidence of toxic effects of fungi and bacteria, 126 and exposure to damp indoor of exposure data, 114­115 environments, 248­249 Federal Emergency Management Agency of health effects, 186­189 of whether the space has been (FEMA), 272, 324 successfully remediated, 299­300 FEMA. See Federal Emergency Management Agency Evaluation criteria, 23­25 biologic gradient (dose-response FEV. See Forced expiratory volume relationship), 24 Findings about dampness in buildings, 76­77 biologic plausibility and coherence, 24 consistency of association, 24 about exposure assessment, 115­116 strength of association, 23­24 regarding prevention and remediation of damp indoor environments, temporally correct association, 24 Evaluation of the epidemiologic evidence, 304­305 21­25 regarding public health response, 327­ 328 conclusions regarding epidemiologic evidence, 26­27 regarding the toxic effects of fungi and considerations in assessing the strength bacteria, 170­171 First National Environmental Health Survey of epidemiologic evidence, 23­25 methodologic considerations, 21­23 of Child Care Centers, 316

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348 INDEX FISH. See Fluorescent in situ hybridization H Flavobacterium, 59 Fluorescent in situ hybridization (FISH), 102 Harvard Six Cities Study, 313 Forced expiratory volume (FEV), 96 Health complaints and disorders, 243­252. Forced vital capacity (FVC), 211n See also Human health effects Fungal contamination, ascertaining extent associated with damp indoor and location of, 288­292 environments Fungal Contamination in Buildings: A cancers, 250­251 Guide to Recognition and fatigue, 245­246 Management, 274 gastrointestinal tract, 245 Fungal genera, found in infested building nausea and related symptoms and materials, 64 exposure to damp indoor Fungi environments, 246 associated with dampness or mold neuropsychiatric symptoms, 247­250 growth in buildings, 65 reproductive effects, 251 on building materials, 59­65 rheumatologic and other immune concentrations in the environment, diseases, 251­252 110 sick building syndrome, 250 in outdoor and indoor air, 56­59 skin, 243­245 Fusarium, 57, 71, 131, 164, 235 Healthy Homes Initiative, 323­324, 326 FVC. See Forced vital capacity Healthy persons, respiratory infections in, 236­237 Heating, ventilation, and air conditioning G (HVAC) systems, 5, 42­44, 75­78, 273, 275, 296­297 Ganoderma, 57 Hemosiderosis, 238­243 GAO. See General Accounting Office HEPA. See High-efficiency particulate air Gas chromatography (GC), 104 High-efficiency particulate air (HEPA), Gas chromatography-mass spectrometry 272­273 (GCMS), 103­104 filtering in a fan, 299 Gastrointestinal tract, 245 filtering in a vacuum, 298 GC. See Gas chromatography High-performance liquid chromatography GCMS. See Gas chromatography-mass (HPLC), 104 spectrometry Histories of buildings and occupants, General Accounting Office (GAO), 48 collecting, 287­288 Geotrichum, 57 History of "toxic mold," 334 Gliotoxin, 163 Housing Global Initiative for Chronic Obstructive public health response, 312­313 Lung Disease (GOLD), 213 in the United States, 1 GOLD. See Global Initiative for Chronic HP. See Hypersensitivity pneumonitis Obstructive Lung Disease HPLC. See High-performance liquid Grooved Pegboard Test, 247 chromatography Guidelines Human health effects associated with damp from the EPA, 274, 299, 324 indoor environments, 9­10, 183­ for prevention of dampness-related 269 problems, 320­321 evaluating health effects, 186­189 Guidelines for the Assessment of other health complaints and disorders, Bioaerosols in the Indoor 243­252 Environment, 272, 274 recommendations, 254­255 research needs, 254­255

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INDEX 349 respiratory symptoms, 189­208 Indoor air quality (IAQ), 48 respiratory tract disorders, 208­243 Indoor Air Quality Tools for Schools Humans and human cells, respiratory effects Program, 317 in, 146­150 Indoor Allergens, 56, 68, 184 Humidifier fever, 233 Indoor Climate Work Environment HVAC. See Heating, ventilation, and air questionnaire, 287 conditioning systems Indoor:outdoor (I/O) concentration ratios, Hyalodendron, 57 59 Hypersensitivity pneumonitis (HP), 231­233 Inflammatory responses to bacteria and fungi in mice, 137­138 Information bias, 22 I Information gathering, 19­20 Inhalation fevers, 233­234 I/O. See Indoor:outdoor concentration humidifier fever, 233 ratios organic dust toxic syndrome (ODTS), IAQ. See Indoor air quality 233 IARC. See International Agency for Inhaled spores, deposited in respirable Research on Cancer (alveolar) area of lung, 129 Identification of the vulnerable population, Institute of Inspection, Cleaning, and extent of contamination, and Restoration Certification, 274n moisture dynamic, 287­295 Institute of Medicine (IOM), 17, 19, 56, ascertaining extent and location of 184, 215, 302, 314 fungal contamination, 288­292 Committee on Curriculum collecting histories of building and Development in Environmental occupants, 287­288 Medicine, 325 identifying moisture dynamic, 293­295 Internal dose, 94 Idiopathic pulmonary hemosiderosis. See International Agency for Research on Acute idiopathic pulmonary Cancer (IARC), 26, 169 hemorrhage in infants 2000 International Residential Code, 53 Illinois Department of Health, 323 International Society of Indoor Air Quality Immune-compromised persons, respiratory (ISIAQ), 274­275, 299, 301 infections in, 235­236 IOM. See Institute of Medicine Immunotoxicity, 150­157 ISIAQ. See International Society of Indoor immunoactive mycotoxins and effects, Air Quality 152­153 Impactor methods, for assessing microorganisms, 101 J In vitro experiments, on mucous membrane irritation and inflammation, 134­ Judgment, role of, 21 135 Inadequate or insufficient evidence to determine whether or not an L association exists, 27 Indirect exposure-assessment methods, 104­ LAL. See Limulus amebocyte lysate Leptosphaeria, 57 110 biomarkers, 109 Light, 55n dampness definitions and associated Limited or suggestive evidence of an association definition, 27 environmental assessments, 4, 106­ 108 Limiting conditions, for fungal growth on predictive exposure models, 109­110 building materials, 335 Limiting moisture sources, and drying the signs and measurements of dampness, moisture, or mold, 104­109 materials, 297­298

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350 INDEX Limulus amebocyte lysate (LAL), 91, 103, fungi and bacteria in outdoor and 114 indoor air, 56­59 L. polyphemus, 103 fungi and bacteria on building Lipopolysaccharides (LPSs), 103 materials, 59­65 Liquid impinger methods, for assessing MM-040-EA Indoor Climate Work microorganisms, 101 Environment questionnaire, 287 LOAELs. See Lowest-observed-adverse- Moisture effect levels buildings as microbial habitats, 54­55 Location, of dampness in buildings, 50­51 definitions, 30­31 Lower respiratory tract (LRT) effects, 194­ determinants of microbial growth 208 indoors, 55­56 cough, 194­201 in heating, ventilating, and air shortness of breath (dyspnea), 208 conditioning systems, 42­44 wheeze, 201­208 role in microbial growth, 54­56 Lowest-observed-adverse-effect levels Moisture content (MC), 30­31, 73 (LOAELs), 126 Moisture dynamics in buildings LPSs. See Lipopolysaccharides condensation and high humidity, 39­ LRT. See Lower respiratory tract effects 44 construction moisture, 38 how buildings get wet, 32­44 M plumbing and wet rooms, 37­38 rainwater and groundwater, 33­37 MC. See Moisture content Moisture meters, 289 Memnoniella echinata, 128, 146­147, 149 Mold and moisture control activities at Methodologic considerations, 21­23 HUD, 333 analytic bias, 22­23 Mold-remediation guidance documents, confounding, 23 comparison of, 276­285 uncertainty and confidence, 21­22 Mold Remediation in Schools and Microbial agents, components of, 65­72 Commercial Buildings, 274 Microbial growth indoors, determinants of, Monitoring, of public health approaches to 55­56 damp indoor environments, 315­ Microbial volatile organic compounds 317 (MVOCs), 5, 66, 69, 90, 165 Morbidity and Mortality Weekly Report, Microbiology science, gaps in building, 71 233 Micrococcus, 59 Mucor plumbeus, 55 M. luteus, 134 Mucous membrane irritation and "Microenvironmental model" approach, inflammation, 133­136 97­98 animal experiments, 136 Microorganism constituents, 6 in vitro experiments, 134­135 allergens, 6 Mucous membrane irritation syndrome, (13)-glucans, 6, 66, 237 212­213 endotoxins, 6 MVOCs. See Microbial volatile organic fungal extracellular polysaccharides, 6 compounds fungal spores, 6 Mycobacterium obvis, 154 Microorganisms occurring in indoor spaces M. scrofulaceum, 135 and on building materials, 56­73 M. terrae, 135­136, 217 associated with dampness or mold Mycotoxins, and the microorganisms that growth in buildings, 65 produce them, 127 building materials and microbial growth, 72­73 components of microbial agents, 65­ 72

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INDEX 351 N P National Cooperative Inner-City Asthma Paecilomyces, 57 Study, 323 Paralysis-inducing neurotoxins, 162 National Health and Nutrition Examination PCR. See Polymerase chain reaction Survey (NHANES II), 313 technologies National Institute for Occupational Safety Peak expiratory flow (PEF), 96, 211 and Health, 48 PEF. See Peak expiratory flow National Survey of Lead and Allergens in Penicillium, 57, 66, 70­71, 128, 145, 157, Housing (NSLAH), 316 161­162, 200, 216, 225, 230­231, Nausea and related symptoms, and 236, 291 exposure to damp indoor P. aurentiogriseum, 149­150, 169 environments, 246 P. bravicompactum, 54 Neuropsychiatric symptoms, 247­250 P. chrysogenum, 149, 230, 292, 297 Neurospora, 57 P. citreo-viride, 162 Neurotoxic effects of indoor molds and P. crustosum, 162 bacteria, 157­164 P. cyclopium, 169 gliotoxin, 163 P. expansum, 149 ochratoxin, 162­163 P. glabrum, 149 paralysis-inducing neurotoxins, 162 P. simplicissimum, 162 tremorgenic toxins, 161­162 P. spinulosum, 135­136, 217 trichothecenes, 163­164 P. verruculosum var. cyclopium, 162, Neurotoxic mycotoxins and effects, 158­ 169 161 P. viridicatum, 149, 169 New York City Department of Health Peptidoglycans, 68­69 (NYCDOH), 273­275, 287, 299, Personal vs area sampling, 97­98 324 Phenylspirodrimanes, 147 NHANES II. See National Health and Planning remediation activities, 295­301 Nutrition Examination Survey decontaminating or removing damaged NOAELS. See No-observed-adverse-effect materials as appropriate, 298­299 levels eliminating or limiting moisture No-observed-adverse-effect levels sources and drying the materials, (NOAELs), 126, 145 297­298 Nocardiopsis, 71 establishing appropriate containment Nonculture methods, for assessing and worker and occupant microorganisms, 102­103 protection, 295­297 North American Air Duct Cleaners evaluating whether the space has been Association, 296 successfully remediated, 299­300 NSLAH. See National Survey of Lead and reassembling the space to prevent Allergens in Housing recurrence by controlling moisture NYCDOH. See New York City Department and nutrients, 301 of Health Plumbing and wet rooms, 37­38 Polymerase chain reaction (PCR) technologies, 103 O Polyvinyl chloride (PVC) materials, 73­74 Potential for water and moisture sources Occupants of buildings leading to excessive indoor collecting histories of, 287­288 dampness, 3 as sources of moisture, 41­42 Predictive exposure models, 109­110 Ochratoxin, 162­163 Prevalence, 44­49 ODTS. See Organic dust toxic syndrome of dampness in buildings, 44­49 Organic dust toxic syndrome (ODTS), 233

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352 INDEX of reported housing water leaks, 47 R of signs of building dampness, 45­46 Prevention and remediation of damp indoor Rainwater and groundwater, 33­37 environments, 12­13, 270­310 Reactivity issues, 94 effects of air and surface cleaning and Reassembling the space to prevent ventilation, 301­304 recurrence by controlling moisture findings, 304­305 and nutrients, 301 prevention, 270­271 Recommendations, 11­12 public health response, 14­16 about dampness in buildings, 77 published guidance for mold about exposure assessment, 115­116 remediation, 271­284 regarding human health effects recommendations, 305 associated with damp indoor research needs, 305­306 environments, 254­255 tasks involved in remediation, regarding prevention and remediation 284­301 of damp indoor environments, 305 Pseudomonas, 59, 134, 234 regarding public health response, 328­ P. fluorescens, 134 329 Public health approaches to damp indoor regarding the toxic effects of fungi and environments, 314­327 bacteria, 170­171 assessment and monitoring, 315­317 Regrowth of mold after remediation, 299­ collaboration, 326­327 300 economic and other incentives, 319­320 Regulations, building codes, and building- education and training, 324­326 related contracts, modification of, guidelines for prevention of dampness- 318 related problems, 320­321 Relative humidity (RH), 31, 39­40, 51­52, modification of regulations, building 54­55, 72­74, 286, 294 codes, and building-related Remediation activities, 284­301, 334 contracts, 318 decontaminating or removing damaged public-health-oriented research and materials as appropriate, 298­299 demonstration, 321­323 eliminating or limiting moisture Public health response, 14­16, 311­332 sources and drying the materials, barriers to the adoption of dampness 297­298 prevention and reduction measures, establishing appropriate containment 313­314 and worker and occupant findings, 327­328 protection, 295­297 public health and housing, 312­313 evaluating whether the space has been public health approaches to damp successfully remediated, 299­300 indoor environments, 314­327 identifying the vulnerable population, recommendations, 328­329 extent of contamination, and research needs, 328­329 moisture dynamic, 287­295 Publication bias, 20­21 reassembling the space to prevent Published guidance for mold remediation, recurrence by controlling moisture 271­284 and nutrients, 301 comparison of seven mold-remediation taking emergency actions to stop water guidance documents, 276­285 intrusion if needed, 286 Pulmonary hemorrhage, 238­243 Repairing Your Flooded Home, 272 in infants, 146­149 Report of the Microbial Growth Task PVC. See Polyvinyl chloride materials Force, 274 Reported prevalence of signs of building dampness, 45­46 Reproductive effects, 251

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INDEX 353 RER. See Rough endoplasmic reticulum pulmonary hemorrhage or Research approach to epidemiologic hemosiderosis, 238­243 evidence, 19­21 respiratory infections, 235­238 information gathering, 19­20 sinusitis, 208­211 publication bias, 20­21 Response bias, 23 role of judgment, 21 Reverse causality bias, 22 Research needs RH. See Relative humidity concerning dampness in buildings, 77­ Rheumatologic and other immune diseases, 78 251­252 in exposure assessment, 115­116 Rhinocladiella, 57 public-health-oriented, 321­323 Risk factors for moisture problems, 51­54 regarding human health effects barriers to prevention, 52­54 associated with damp indoor building characteristics, 51­52 environments, 254­255 Risk-relevant exposure metric, 91 regarding prevention and remediation Rough endoplasmic reticulum (RER), 144 of damp indoor environments, 305­306 regarding public health response, 328­ S 329 Saccharomyces, 57, 216 regarding the toxic effects of fungi and bacteria, 170­171 Salmonella, 154 Respiratory cells and tissues, 136­150 Sampling strategies, 94­101 personal vs area sampling, 97­98 animals and animal cells, 139­146 effects of indoor molds and bacteria, settled dust vs airborne measurements, 136­150 94­97 when, where, and how often to humans and human cells, 146­150 inflammatory and toxic responses to sample, 98­101 bacteria and fungi in mice, 137­138 San Diego Neuropsychological Test Battery, 247 pulmonary hemorrhage in infants, 146­149 SBS. See Sick building syndrome Respiratory health, related to indoor Scanning electron microscopy (SEM), 102 Seattle-King County Healthy Homes endotoxin exposure, 112­113 Respiratory infections, 235­238 Project, 322 in immune-compromised persons, 235­ Selection bias, 22 SEM. See Scanning electron microscopy 236 in otherwise-healthy persons, 236­237 Sensory irritation, 164­165 Respiratory symptoms, 189­208 Settled dust vs airborne measurements, 94­ 97 lower respiratory tract (LRT) effects, 194­208 Severity, of dampness in buildings, 49­50 upper respiratory tract (URT) effects, Shortness of breath (dyspnea), 208 dyspnea and exposure to damp indoor 189­194 Respiratory tract disorders, 208­243 environment, 209 airflow obstruction, 211­212 Sick building syndrome (SBS), 250 Signs and measurements of dampness, asthma, 215­231 chronic obstructive pulmonary disease moisture, or mold, 104­109 (COPD), 211, 213­215 Sinusitis, 208­211 Skin, 243­245 hypersensitivity pneumonitis (HP), 231­233 problems with, and exposure to damp inhalation fevers, 233­234 indoor environments, 244 Smart Growth in America, 53­54 mucous membrane irritation syndrome, 212­213 Spore-deposition coefficients of mold genera in indoor environments, 129

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354 INDEX Spore-trap samples, 291 Toxic effects of indoor molds and bacteria, Spores 133­170 and cells of bacteria, 67 carcinogenesis, 166­170 and fragments of fungi, 66 carcinogenic effects of mycotoxins, Stachybotrys, 66, 132, 134­135, 241­242 167­168 S. alternans, 70 dermal toxicity, 166 S. atra, 55, 70, 139­140, 166, 239, immunoactive mycotoxins and effects, 273 152­153 S. chartarum, 11, 17, 58, 70, 109, 128, immunotoxicity, 150­157 135, 140­149, 166, 170, 188, 239­ mucous membrane irritation and 241, 247 inflammation, 133­136 Staphylococcus, 134 neurotoxic effects, 157­164 Stockholm Indoor Environment respiratory effects, 136­150 Questionnaire, 287 sensory irritation, 164­165 Strength of association, 23­24 toxic responses to bacteria and fungi in Streptomyces, 59, 67, 71, 134 mice, 137­138 S. annlatus, 134­135, 252 Toxic products of microbial secondary S. californicus, 71n, 130, 134­136, metabolism, 69­71 217 Training, regarding public health Structural components of fungi and approaches to damp indoor bacteria, 68­69 environments, 324­326 acetylglucosamine polymer fibrils, 68 Tremorgenic toxins, 161­162 endotoxins, 68 Trichoderma, 57, 71 peptidoglycans, 68­69 T. viride, 127, 145, 153, 160, 162 Sufficient evidence Trichophyton, 216 of an association definition, 26 Trichosporon cutaneum, 232 of a causal relationship definition, 26 Trichothecene mycotoxins, 109, 131, 147, 155, 164 Trichothecenes, 163­164 T Tritirachium, 57 Tasks involved in remediation, 284­301 identifying the vulnerable population, U extent of contamination, and moisture dynamic, 287­295 Ulocladium consortiale, 55 planning remediation activities, 295­ Ultraviolet germicidal irradiation (UVGI), 44 301 Uncertainty, statistical characterization of, taking emergency actions to stop water 21­22 intrusion if needed, 286 Upper respiratory tract (URT) effects, 189­ Temporally correct association, 24 194 Thermophilic actinomycetes, 186 symptoms, and exposure to damp Thin-layer chromatography, 104 indoor environment, 190­192 Toxic effects of fungi and bacteria, 7­8, URT. See Upper respiratory tract effects 125­182 U.S. Census American Housing Survey, 44 bioavailability and route of exposure, U.S. Department of Agriculture (USDA), 126­133 272, 324 considerations in evaluating the U.S. Department of Housing and Urban evidence, 126 Development (HUD), 15, 323, defined, 139n 328 findings, 170­171 Healthy Homes Initiative, 323­324, recommendations, 170­171 326 research needs, 170­171

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INDEX 355 U.S. Environmental Protection Agency Workshop topics, 333­335 (EPA) acute idiopathic pulmonary guidelines, 274, 299, 324 hemorrhage in infants, 333 Indoor Air Quality Tools for Schools clinical issues, 334 Program, 317 EPA mold-related activities, 333 mold-related activities, 333 epidemiology of indoor damp spaces, U.S. Pharmacopoeia, 111n 334 U.S. Toxic Mold Safety and Protection Act experimental methods to assess the of 2003, 317n pulmonary effects of fungi, 334 UVGI. See Ultraviolet germicidal irradiation history and measurement of "toxic mold," 334 investigation and remediation of damp V indoor spaces, 334 limiting conditions for fungal growth Vacuum cleaner, HEPA-filtered, 298 on building materials, 335 Vapor-emission tests, 295 mold and moisture control activities at VOCs. See Volatile organic compounds HUD, 333 Volatile organic compounds (VOCs), 5, 66, mold-related research activities in 69, 90, 94, 165, 187 Finland, 333 toxicology, 335 toxigenic fungi as significant W environmental health threats, 333 Wallemia sebi, 54 Wheeze, 201­208 and exposure to damp indoor Z environments, 203­207 Zygomycetes, 231, 236 Worker and occupant protection, establishing appropriate, 295­297

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