5

Dampness, Moisture, and Flooding

INTRODUCTION

This chapter addresses indoor environmental quality (IEQ) problems associated with moisture, condensation, and inundation and the possible effects of climate change on these problems. There is an extensive literature on the effects of indoor dampness on health, including an Institute of Medicine (IOM) report (IOM, 2004) that remains salient and is drawn on heavily in this chapter. The committee did not attempt to re-examine all the scientific evidence considered in the IOM report and other efforts—an undertaking beyond the scope of this study—but instead highlights their findings and other research relevant to the consideration of the health effects of alterations in IEQ induced by climate change.

The chapter’s focus is on fungi1 and bacteria—microbial agents that grow in the presence of water—and products of damaged building materials. They produce biologic and chemical emissions that can lead to irritant, allergic, other immunologic, or toxic responses. Other chapters address some issues relevant to occupants’ exposures to those emissions. Ventilation, which is discussed in Chapter 8, has an effect on exposure: levels of indoor contaminants are higher in spaces that have lower air-exchange

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1 Fungi have eukaryotic cells as do animals and plants but are a separate kingdom. Most consist of masses of filaments, live off dead or decaying organic matter, and reproduce by spores. Visible fungal colonies found indoors are commonly called mold (mould), sometimes mildew. This report, following the convention of earlier IOM reports and much of the literature on indoor environments, uses the terms fungus and mold interchangeably to refer to the microorganisms.



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5 Dampness, Moisture, and Flooding INTRODUCTION This chapter addresses indoor environmental quality (IEQ) problems associated with moisture, condensation, and inundation and the possible effects of climate change on these problems. There is an extensive litera- ture on the effects of indoor dampness on health, including an Institute of Medicine (IOM) report (IOM, 2004) that remains salient and is drawn on heavily in this chapter. The committee did not attempt to re-examine all the scientific evidence considered in the IOM report and other efforts—an undertaking beyond the scope of this study—but instead highlights their findings and other research relevant to the consideration of the health ef- fects of alterations in IEQ induced by climate change. The chapter’s focus is on fungi1 and bacteria—microbial agents that grow in the presence of water—and products of damaged building materi- als. They produce biologic and chemical emissions that can lead to irritant, allergic, other immunologic, or toxic responses. Other chapters address some issues relevant to occupants’ exposures to those emissions. Ventila- tion, which is discussed in Chapter 8, has an effect on exposure: levels of indoor contaminants are higher in spaces that have lower air-exchange 1 Fungi have eukaryotic cells as do animals and plants but are a separate kingdom. Most consist of masses of filaments, live off dead or decaying organic matter, and reproduce by spores. Visible fungal colonies found indoors are commonly called mold (mould), sometimes mildew. This report, following the convention of earlier IOM reports and much of the litera- ture on indoor environments, uses the terms fungus and mold interchangeably to refer to the microorganisms. 133

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134 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH rates. Some microbial agents also cause infections (this topic is addressed in Chapter 6). CLIMATE CHANGE AND INDOOR DAMPNESS AND FLOODING The effects of climate change on moisture indoors are driven by several factors, including extreme weather events, local changes in temperature and humidity, and the adaptations that occupants make and mitigation strate- gies that they use in response to changed environmental conditions. The US Global Change Research Program notes that increases in air temperatures and increased frequency and intensity of heavy downpours have already been observed in the United States and that likely future changes “include more intense hurricanes with related increases in wind, rain, and storm surges” (USGCRP, 2009). Extreme weather conditions may lead to breakdowns in building envelopes followed by sudden infiltration of water into indoor spaces. Dampness problems and water intrusion create conditions favorable to the growth of fungi and bacteria and may cause building materials to decay or corrode and lead to off-gassing of chemicals. In areas where the climate is warm and humid for more months of the year, air conditioning will be used more often. Well-designed and properly operating heating, ventilation, and air conditioning (HVAC) systems can ameliorate humid conditions; poorly designed or maintained systems may introduce moisture and create condensation on indoor surfaces.2 Mold- growth prevention and remediation may also introduce fungicides and other agents into the indoor environment, which can lead to adverse expo- sures of occupants. Flooding as a result of extreme weather events can have profound health and economic effects. In 2010, there were 103 flood-related fatali- ties in the United States, a significantly higher number than the 10-year average of 71 measured between 2001 and 2010 (National Oceanic and Atmospheric Administration, 2011). In that same year, floods were part of six of the seven most costly insurance loss events in the United States; events that were responsible for $6.3 billion in losses (Swiss Re, 2011). Jonkman and colleagues (2009) estimate that two-thirds of the 771 known fatalities of Hurricane Katrina were the direct result of flooding and that additional fatalities were associated with flood-related circumstances including lack of access to potable water or medical services and exposure to extreme heat as a result of power outages. Altered climatic conditions will not introduce new dampness problems into the indoor environment but may make existing problems more wide- 2 This topic is addressed in Chapter 7.

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135 DAMPNESS, MOISTURE, AND FLOODING spread and more severe and thus increase the urgency with which preven- tion and interventions must be pursued. INDOOR DAMPNESS Almost all buildings experience excessive moisture, leaks, or flooding at some point. Research regarding the sources and causes of indoor dampness was addressed in detail in a previous IOM report (2004), which described how and where buildings become wet; reviewed the signs of dampness, how dampness is measured, and what is known about its prevalence and characteristics, such as severity, location, and duration; discussed the risk factors for moisture problems; reviewed how dampness influences indoor microbial growth and chemical emissions; cataloged the various agents that may be present in damp environments; and addressed the influence of building materials on microbial growth and emissions. That effort’s findings are briefly summarized below. Dampness—a term used to describe a variety of moisture problems, including high relative humidity, condensation, water ponding, and other signs of excess moisture or microbial growth—is prevalent in residential housing. The prevalence and significance of dampness are less well under- stood in nonresidential structures, such as office buildings and schools, than in residential buildings. There is no single cause of excessive indoor dampness, and the primary risk factors for it differ among climates, geographic areas, and building types. The prevalence of dampness problems appears to increase as build- ings age and deteriorate, but some modern construction techniques and materials and the presence of air-conditioning can increase the risk of dampness problems. The prevalence and nature of these problems suggest that what is known about their causes and prevention is not consistently applied in building design, construction, maintenance, and use. DAMPNESS AND HEALTH Efforts to quantify the effects of indoor environmental factors on hu- man health often rely on markers of dampness indoors to characterize risk. This approach reflects recognition that indoor moisture is associated with adverse health outcomes and that exposures to emissions from mold, bacteria, and damaged materials increase when indoor environments are chronically wet or damp. There have been three large-scale reviews of the relationship between indoor dampness and human health in the past decade. In 2004, IOM is- sued Damp Indoor Spaces and Health. The World Health Organization (WHO) released WHO Guidelines for Indoor Air Quality: Dampness and

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136 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH Mould in 2009, and researchers involved in the WHO effort updated and expanded that review in 2011 (Mendell et al., 2011). The IOM report reviewed literature published up to late 2003 on a wide array of health effects. Among the major findings were that sufficient evidence existed for associating the presence of mold or other agents in damp buildings with nasal and throat symptoms, cough, wheeze, asthma exacerbation, and hypersensitivity pneumonitis in susceptible persons. The committee responsible for the IOM report concluded that limited or sugges- tive evidence existed for associating exposure to damp indoor environments with shortness of breath, asthma, and, in otherwise healthy children, lower respiratory disease. Tables 5-1 and 5-2 summarize the report’s conclusions, and Box 5-1 summarizes the categories used to classify the strength of the evidence. The WHO guidelines covered literature published up to July 2007 (WHO, 2009). Their authors took the same approach to evaluating and categorizing evidence for dampness as was used in the IOM report but ex- TABLE 5-1 Summary of Findings Regarding the Association Between Health Outcomes and Exposure to Damp Indoor Environmentsa Sufficient Evidence of a Causal Relationship (no outcomes met this definition) Sufficient Evidence of an Association Upper respiratory (nasal and throat) tract Wheeze symptoms Asthma symptoms in sensitized persons Cough Limited or Suggestive Evidence of an Association Dyspnea (shortness of breath) Asthma development Lower respiratory illness in otherwise healthy children Inadequate or Insufficient Evidence to Determine Whether an Association Exists Airflow obstruction (in otherwise healthy Skin symptoms persons) Gastrointestinal tract problems Mucous membrane irritation syndrome Fatigue Chronic obstructive pulmonary disease Neuropsychiatric symptoms Inhalation fevers (nonoccupational Cancer exposures) Reproductive effects Lower respiratory illness in otherwise Rheumatologic and other immune diseases healthy adults Acute idiopathic pulmonary hemorrhage in infants a The categories of evidence are summarized in Box 5-1 and explicated in Damp Indoor Spaces and Health (IOM, 2004).

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137 DAMPNESS, MOISTURE, AND FLOODING TABLE 5-2 Summary of Findings Regarding the Association Between Health Outcomes and the Presence of Mold or Other Agents in Damp Indoor Environmentsa Sufficient Evidence of a Causal Relationship (no outcomes met this definition) Sufficient Evidence of an Association Upper respiratory (nasal and throat) tract Wheeze symptoms Asthma symptoms in sensitized persons Cough Hypersensitivity pneumonitis in susceptible persons Limited or Suggestive Evidence of an Association Lower respiratory illness in otherwise healthy children Inadequate or Insufficient Evidence to Determine Whether an Association Exists Dyspnea (shortness of breath) Skin symptoms Asthma development Gastrointestinal tract problems Airflow obstruction (in otherwise healthy Fatigue persons) Neuropsychiatric symptoms Mucous membrane irritation syndrome Cancer Chronic obstructive pulmonary disease Reproductive effects Inhalation fevers (nonoccupational Rheumatologic and other immune diseases exposures) Lower respiratory illness in otherwise healthy adults Acute idiopathic pulmonary hemorrhage in infants a The categories of evidence are summarized in Box 5-1 and explicated in Damp Indoor Spaces and Health (IOM, 2004). amined a larger set of health outcomes. Their analysis supported the IOM report findings that there was sufficient evidence to conclude that there is an association between indoor dampness-related agents3 and asthma exacerbation, upper respiratory tract symptoms, cough, and wheeze. In addition, they determined that two outcomes not evaluated in the IOM report—current asthma and respiratory infections—and two outcomes that had been placed in the category of limited or suggestive evidence—asthma development and dyspnea (shortness of breath)—merited inclusion in the sufficient evidence category. Evidence regarding allergic rhinitis, bronchitis, 3Defined by the authors as “evidence of visible water damage, visible mold, mold odor, or similar related factors.”

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138 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH BOX 5-1 Summary of the Categories of Evidence Used in Damp Indoor Spaces and Health (IOM, 2004) Sufficient Evidence of a Causal Relationship Evidence is sufficient to conclude that a causal relationship exists between the agent and the outcome. That is, the evidence fulfills the criteria for “sufficient evi- dence of an association” and, in addition, satisfies the following criteria: strength of association, biologic gradient, consistency of association, biologic plausibility and coherence, and temporally correct association. Sufficient Evidence of an Association Evidence is sufficient to conclude that there is an association. That is, an as- sociation between the agent and the outcome has been observed in studies in which chance, bias, and confounding can be ruled out with reasonable confidence. Limited or Suggestive Evidence of an Association Evidence is suggestive of an association between the agent and the outcome but is limited because chance, bias, and confounding cannot be ruled out with confidence. Inadequate or Insufficient Evidence to Determine Whether an Association Exists The available studies are of insufficient quality, consistency, or statistical power to permit a conclusion regarding the presence of an association. Alternatively, no studies exist that examine the relationship. and eczema—which had not been separately evaluated in the IOM report— was deemed limited or suggestive. Mendell and colleagues carried the WHO review forward to late 2009. On the basis of their examination of previously available and newly pub- lished evidence, they raised bronchitis, allergic rhinitis, eczema, and ever- diagnosed asthma (that is, without regard to whether there was a current diagnosis of asthma) to the sufficient-evidence category. Epidemiologic re- search also yielded limited or suggestive evidence of an association between dampness-related agents and the “common cold” and “allergy/atopy.” The sections that follow provide some background on asthma, other re- spiratory ailments, and other conditions mediated by an immune response. They also highlight some of the recent literature on those health outcomes. Asthma is a prominent public-health concern because of rising rates and substantial effect on health, productivity, and health-care costs, but other immunologic conditions related to dampness are also problematic and may increase if sustained high levels of indoor moisture become more common (Mudarri and Fisk, 2007).

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139 DAMPNESS, MOISTURE, AND FLOODING Asthma and Other Respiratory Ailments In the United States, asthma from all causes increased in frequency and severity in the two decades from 1980 to 2000. From 1980 to 1996, the prevalence of asthma increased by 74%, and the incidence from 1.2 per 1,000 per year to 4.7 per 1,000 per year (Mannino et al., 2002). An assessment of annual asthma incidence in the total US population, using the National Health Interview Survey (NHIS) data for 1980–1996, esti- mated that 7.2–12.4% of those with prevalent asthma noted an onset in the preceding year (Rudd and Moorman, 2007). Data from the NHIS, the National Ambulatory Medical Care Survey, the National Hospital Ambula- tory Medical Care Survey, the National Hospital Discharge Survey, and the National Vital Statistics System indicated that an estimated 8.2% of adults in the United States reported current asthma and that 4.2% of adults had at least one asthma attack in the previous year (Akinbami, 2011). Efforts to estimate the burden of asthma that can be attributed to damp indoor spaces are limited by a lack of data on the prevalence of dampness indoors and by the absence of consistent occupational or environmental information on cases of asthma. Reviews estimate that one-fifth of current asthma in the United States is attributable to dampness in homes (Fisk et al., 2007) and that new-onset asthma or asthma-like symptoms may occur more frequently in people who are exposed to moisture or mold at home or at work (Sahakian et al., 2008). One study of office workers who oc- cupied a water-damaged office building at a particular time documented an asthma incidence rate more than 7 times higher after occupancy than in the years before occupancy (1.9/1,000 person-years before building occupancy; 14.5/1,000 person-years after) (Cox-Ganser et al., 2005). Later analysis of that workforce with regard to exposure to mold, measured as culturable fungi and ergosterol concentrations in floor dust, demonstrated an excess risk of new-onset asthma at higher levels of exposure (Park et al., 2008). Papers published since Mendell et al. (2011) completed their litera- ture review in late 2009 have tended to support the conclusions drawn by them. A 2010 study of possible cases of occupational asthma in Finland determined that exposure to dampness and mold in the workplace was associated with new-onset adult asthma and aggravated the symptoms of asthmatics (Karvala et al., 2010). Nguyen and colleagues’ analysis of the results of The National Asthma Survey—New York State found that there was a positive relationship between asthma symptoms, mold, and humid- ity in households that had at least one asthmatic adult or child (Nguyen et al., 2010). A study in three urban cities in Korea established that students experi- enced higher levels of wheezing in classrooms that were damp, had visible mold growth, or had water damage (Kim et al., 2011). Sun et al. (2010) examined allergic symptoms, including wheezing, in students living in dor-

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140 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH mitories in Tianjin University, China, during the 2006–2007 school year. The students reported more moisture accumulation and moldy odors and higher levels of wheezing and rhinitis in summer than winter months. In contrast, Holme and colleagues’ study of children in Sweden did not find an association between visible signs of dampness and spore concentration in indoor air or a relationship between spore concentrations and children’s allergy and asthma symptoms (Holme et al., 2010). Other Immunologic Conditions Epidemiologic studies have shown that some immunologic outcomes in addition to asthma may be related to moisture incursion in buildings. Sarcoidosis is more frequent in occupants of water-damaged buildings (Cox-Ganser et al., 2005; Laney et al., 2009; Newman et al., 2004), includ- ing school buildings (Dangman et al., 2005). It is important to note that in each of the cited investigations of sarcoidosis, the researchers documented increases in asthma and asthma-like symptoms. It is biologically plausible that exposure to bacteria (notably the en- dotoxin that is a cell-wall component of some bacteria) and fungi that are often present in damp indoor environments could trigger immune responses that lead to inflammation. Experimental studies have demonstrated that common microbial constituents of damp indoor environments can be po- tent inducers of inflammatory responses (Hirvonen et al., 2005). Research- ers believe that granuloma formation in sarcoidosis is in response to an unidentified antigenic stimulus that induces a local Th1-cell–mediated im- mune response (DuBois et al., 2003). Chronic stimulation of macrophages causes the continuing release of inflammatory cytokines (IL-2, IL-12, IFN- c, and TNF-α), which leads to accumulation of Th1 cells at the site of inflammation. That immunologic cycling contributes to expansion of the granuloma structure (Richie, 2005). Autoimmune diseases occur when a person mounts a specific immune response to self antigens that leads to tissue damage. Autoimmune dis- eases are often progressive and debilitating. The burden of autoimmune diseases in the United States is substantial: they affect an estimated 8% of the total population (Fairweather et al., 2008) and disproportionately affect females—more than three-fourths of cases of autoimmune diseases are in women (Dooley and Hogan, 2003; Gleicher and Barad, 2007; Jacobson et al., 1997). In a 2008 review, Fairweather et al. (2008) describe autoimmune diseases as the third-most common category of disease after cancer and cardiovascular disease in the United States. The role of envi- ronmental and occupational exposures is poorly defined (Gold et al., 2007), but exposure to external antigens may trigger and support an autoimmune inflammatory response (Münz et al., 2009), and joint symptoms and dis-

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141 DAMPNESS, MOISTURE, AND FLOODING eases have been associated with microbial exposures related to moisture damage (Luosujärvi et al., 2003). SPECIFIC DAMPNESS-RELATED CONTAMINANTS The principal indoor dampness-related agents that affect health are thought to be molds and bacteria that amplify in the presence of water and products of damaged building materials. As the Damp Indoor Spaces and Health report (IOM, 2004) notes, mold spores are regularly found in indoor air and on surfaces and materials; no indoor space is free of them. There are many species and genera, and those most typically found indoors vary in geographic area, climate, season, and other factors. The availabil- ity of moisture is the primary factor that controls mold growth indoors. Although much attention is focused on mold growth indoors, it is not the only dampness-related microbial agent. Mold growth is often accompa- nied by bacterial growth. Some research on fungi and bacteria focuses on specific components that may be responsible for particular health effects: hyphal (filament) fragments of fungi, protein allergens of microbial origin, structural components of fungal and bacterial cells, and such products as microbial volatile organic compounds (MVOCs) and mycotoxins. Release of those components depends on many physiologic and environmental fac- tors. Dampness can also damage building materials and furnishings, causing or exacerbating the release of chemicals and other nonbiologic particles. The following sections summarize information on those agents and some of the research on their affects on the health of building occupants. Molds Fungi exist as single cells (yeasts), filaments, fruiting bodies, and spores. They are composed of complex chemical compounds, including proteins, glycoproteins, glucans, and proteases. They produce cellular toxins in their competition for access to sources of nutrition in their environment, and their metabolic byproducts include volatile organic compounds (Bush and Portnoy, 2001; Storey et al., 2004). Fungi are ubiquitous in nature and play a critical role in the natural decomposition of organic materials. Indoor spaces without moisture prob- lems generally have air concentrations of mold that are the same as or lower than those outdoors, and the species are the same as those outdoors. Many fungal taxa in the indoor environment are similar to those recovered outdoors, but there are factors in the indoor environment (such as lack of fungicidal ultraviolet radiation from the sun, stable temperature, stable humidity, and shelter) that can allow some fungi to thrive better in the indoor environment.

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142 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH Some structural components of mold can cause an immune response in a person who is exposed mainly through inhalation. Such responses are most commonly allergic and result in rhinitis or asthma. Other responses can lead to hypersensitivity pneumonitis (Ikeda et al., 2002; Lee et al., 2000; Patel et al., 2001; Seuri et al., 2000). The immunologic responses are complex, inasmuch as mold components include antigens and adjuvants that heighten the response to the antigens (Kheradmand et al., 2002; Reed, 2007). Because the active agents that lead to those responses are macromol- ecules on the cell wall, fungal fragments are at least as likely to cause the reactions as are intact spores. Therefore, mold does not have to be living to have an immunologic effect on building occupants. In addition, various mold species share the macromolecules, so an allergy to one species results in an allergy to many (Green et al., 2005a, 2009; Schmechel, 2007). MVOCs include alcohols, esters, aldehydes, and aromatic compounds. They cause the “musty” odor associated with moldy environments. They can cause irritation of mucous membranes (Horner and Miler, 2003), which can lead to irritation of the eyes, nose, throat, and respiratory tract. Irritation of the trigeminal nerve can lead to headache and fatigue. (1→3)-β-D-glucans, components of cell-wall fragments, alter reactions to other agents (Rylander and Lin, 2000) and thus may add to the irritant properties described here. Molds produce mycotoxins under some growth conditions (Jarvis, 2002). There are hundreds of those compounds (Etzel, 2002; Norred et al., 2001), and they include aflatoxins, fumonisins, ochratoxins, rubratoxins, and trichothecenes (Jarvis et al., 1995; Wannemacher and Wiener, 1997). Some have neurotoxic, cytotoxic, immunologic, reproductive, or carcino- genic properties. Although the compounds can exhibit severe toxicity in animals or humans when they are ingested or inhaled at high levels in, for example, agricultural settings, it is less clear whether they have an effect at the levels seen in occupied indoor spaces (IOM, 2004). Mycotoxins have been identified in building materials and settled dust in water-damaged buildings (Bloom et al., 2009). There is evidence that in these environments they contribute to inflammatory responses (Miller et al., 2010). Other po- tential effects are the subject of current investigation. Not all dampness is the same for fungi. During Hurricane Katrina, wind-driven saltwater inundated many homes in Mississippi. The result was severe water damage, but the damage was different from that caused by the sustained floods in New Orleans from Lake Pontchartrain. After the water receded in Mississippi, the homes were dried, and mold growth was easily initiated on building materials and furnishings. New Orleans had homes that were essentially like sealed terrariums for several weeks at the end of summer 2005. A common scene in such buildings was a high-water

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143 DAMPNESS, MOISTURE, AND FLOODING mark on the drywall below which little mold growth was observed. There are two possible explanations for that difference. First, almost all molds need oxygen and cannot sporulate in liquid. That might explain why the previously submerged drywall had less mold growth; the time it took for the water to subside limited mold colonization. Second, flood waters contain the chemicals found in homes themselves (for example, bleach, pesticides, and other cleaning products), chemicals from the soil outside, and possibly other toxicants from nearby industrial or agricultural sources. Some of the chemicals can be fungus inhibitors or can be fungicidal. Perhaps some combination of the two reasons explains the pattern in homes that have endured long-term flooding. The ramifications of long-term flooding could lead to differences in the types of fungi that can proliferate, but research is lacking. One study found that although Cladosporium spores and DNA were abundant and easily collected in air samples from homes, culturable colonies were not as com- mon in heavily damaged homes in New Orleans (Chew et al. 2006). Given that Cladosporium is commonly recovered in home dust and air samples (Chew et al., 2003; Li and Kendrick, 1995; Wouters et al., 2000) and can easily compete with such species as Aspergillus and Penicillium, the lack of growing colonies was perplexing to the researchers. The Centers for Disease Control and Prevention (CDC) has published detailed guidance on how to limit exposure to mold and how to identify and prevent mold-related health effects in the wake of hurricanes and floods (Brandt et al., 2006). It includes exposure-assessment instructions; reme- diation advice (including cleaning of HVAC systems); personal protective equipment recommendations for cleanup personnel; guidance on allergic, infectious, and toxic effects of exposure to mold and other dampness- related agents; adverse health-effects prevention strategies; and advice to public health-authorities. The authors recommend surveillance of com- munity health after hurricanes and floods to identify unrecognized hazards and to gather information that will allow better responses in the future. Few comprehensive epidemiologic studies have been conducted to as- sess respiratory effects of residents who lived in homes after major flooding. What is known is mainly from the Mississippi floods of 1993 and Hurri- canes Katrina and Rita in 2005. Brown and colleagues (2006) estimate that in the New Orleans area alone the latter two events caused at least 110,000 homes to have high levels of mold and bacteria and at least 40,000 to be heavily contaminated. Ross and colleagues assessed mold spores, lung function, and respi- ratory symptoms in 57 asthmatic residents of 44 homes in East Moline, Illinois, in April–October 1994 (Ross et al., 2000). The average mold-spore concentration was 2,190 spores/m3. The researchers found that higher Alternaria concentrations were associated with missing sleep because of

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144 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH asthma (odds ratio [OR], 4.8; 95% Confidence Interval [CI], 1.6–14.6). In their second analysis of the data on the Mississippi floods, the researchers had a slightly different sample size; they assessed mold spores, lung func- tion, and respiratory symptoms in 59 asthmatic residents of 46 homes in East Moline, Illinois, in April–October 1994 (Ross et al., 2002). Concentra- tions in this study averaged 5,692 spores/m3. The researchers found that higher mold-spore concentrations were associated with an improved peak expiratory flow rate (PEFR) and respiratory symptom scores. They attri- bute the paradoxical results partly to self-reported diary cards for PEFR and symptoms. Rabito et al. conducted two studies of mold exposure in post–Hurricane Katrina New Orleans. In the first, the study site was a school that reopened in January 2006, five months after the hurricane (Rabito et al., 2008). Respiratory health questionnaire and spirometric data were collected on children 7–14 years old, and air sampling for fungi in their homes was conducted at baseline and again after two months. The 75th percentile for mold concentration was 100 colony-forming units per cubic meter (cfu/m3) and 70 cfu/m3 at the two times. The concentrations were several orders of magnitude lower than those reported in unoccupied homes immediately after the hurricane (Chew et al., 2006). Nonetheless, there was an overall decrease in mold levels and respiratory symptoms over the study period, and indoor mold levels were low despite reported hurricane damage. Al- though many of the homes had sustained hurricane damage, the authors stressed that their results might not be generalizable to the residents of other homes who did not have the financial means to return to the city and to repair their homes or relocate to a nonflooded area. In the other study by Rabito and colleagues, 529 patients in an allergy clinic were enrolled from December 1, 2005, to December 31, 2008. Mold exposure was assessed with a questionnaire, and mold allergy with a skin- prick test. Mold exposure (defined in terms of extent of home damage or duration of exposure) was not associated with mold allergy. The authors acknowledged that minorities and those without health insurance were un- derrepresented in the study, and this limited generalizability of the results. Overall, the studies did not observe a statistically significant association between mold exposure and respiratory symptoms after flooding events. That result may be influenced by such factors as selection bias, lack of gen- eralizability of the study populations, the healthy-resident effect (whereby healthy residents may be more able to conduct the necessary cleanup and renovation efforts), and difficulties in discerning associations between mold exposure and respiratory morbidity because of the presence of confounding factors (Barbeau et al., 2010). Separately, Dales and colleagues (1991) used questionnaires to gather data on the health and home characteristics of more than 13,000 children

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145 DAMPNESS, MOISTURE, AND FLOODING 5–8 years old in 30 communities across Canada. Flooding, defined as “the appearance of flooding, water damage, or leaks in basement in last year,” was associated with statistically significant ORs for parent-reported cough, wheeze, dyspnea, asthma, bronchitis, chest illness, upper respiratory symp- toms, and eye irritation. The estimates were not adjusted for confounders, but the authors stated that analyses that adjusted for age, sex, race, parental education, presence of environmental tobacco smoke, presence of gas ap- pliances, and hobbies that generate airborne contaminants yielded similar results. Recovery activities after hurricane and floods also present risks. Cummings and colleagues (2008) found that people’s respirator use while they were entering flooded areas and during cleanup and remediation de- creased adverse exposures. They established that disposable-respirator use in water-damaged homes was associated with lower odds of exacerbation of moderate or severe upper respiratory symptoms (OR, 0.51; 95% CI, 0.24– 1.09) and lower respiratory symptoms (OR, 0.33; 95% CI, 0.13–0.83). Methods used to assess exposure to mold and mold components are a major area of research. For example, Ross et al. (2000) found that mold spores reflect a small fraction of the antigen load in a mold-contaminated space. Fungal fragments and conidia contribute allergens at concentrations orders of magnitude greater than mold spores (Green et al., 2005b, 2006). Airborne culturable fungi represent a yet smaller subset of the antigen load. One study assessing asthma morbidity in inner-city children with docu- mented allergy to fungi and focusing on four genera of fungi found that elevated outdoor and indoor levels of culturable mold resulted in increased asthma morbidity (Pongracic et al., 2010). Further studies of the health impacts of post-flood events thus need to assess exposure using a number of methods, including qualitative characterization of contaminated surfaces and fungal fragments. Bacteria Bacteria also thrive in damp indoor environments and often coex- ist with mold. As noted earlier, they can cause inflammatory responses (Hirvonen et al., 2005). Endotoxin, a component of the cell wall of gram- negative bacteria, has been particularly well studied and has been shown either to have direct health effects or to augment the effects of other con- taminants. Endotoxin in house dust has been associated with wheeze in infants (Keman et al., 1998; Park et al., 2001) and with greater severity of asthma in adults who are sensitive to dust mites (Michel, 1996; Michel et al., 1991). In the workplace, endotoxin has been found at high levels in association with hypersensitivity pneumonitis (Rose et al., 1998), and levels in floor dust have been shown to be associated with lower and upper

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146 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH respiratory symptoms, fever and chills, and headache in a large office build- ing and to interact with fungi in the floor dust and lead to higher rates of lower respiratory symptoms in occupants who have increased fungal and endotoxin levels (Park et al., 2006). Emissions from Damaged Building Materials and Furnishings Water damage can lead to decay of building materials and furnishings. Polyvinyl chloride (PVC) floor coatings release phthalates when exposed to water, and phthalates in house dust have been associated with allergic symptoms, eczema, and asthma in children (Bornehag et al., 2004; Jaakkola and Knight, 2008). Increased rates of asthma and allergy symptoms have been associated with damp PVC floor coatings (Bornehag et al., 2005; Tuomainen et al., 2004). Understanding of the complex chemical interac- tions that occur indoors is growing. Research has shown that the indoor chemistry of surfaces (vinyl tile, wall board, and carpet) and the gas phase reactions that can occur when surfaces are disturbed can result in the rapid formation of potential irritants (Forester and Wells, 2009; Ham and Wells, 2008; Harrison and Ham, 2009; Wells et al., 2008). Indoor surfaces can also be important reservoirs of reactant chemicals—such as cleaning agents, pesticides, and paints—that can undergo hydrolysis reactions because of moisture. Characterization of those exposures and their associated health effects is a subject of active research (Anderson et al., 2007, 2010). SUMMARY COMMENTS Dampness problems in buildings are pervasive, and strategies for avoid- ing them well established, although not necessarily widely implemented. There are several sources of guidance on design and retrofit strategies. Lstiburek (2004, 2005a,b, 2006), for example, has produced a series of books that offer design and construction advice specific to various housing types and climatic conditions found in the United States, including advice on avoiding water intrusion and excessive indoor dampness. Operational advice—in particular, proper operation of HVAC systems—for avoiding damp conditions indoors is also available (ASHRAE, 2009). The 2004 IOM report Damp Indoor Spaces and Health summarizes dampness and mold remediation guidelines issued by the New York City Department of Health and Mental Hygiene (NYCDOH 1993, 2000), Health Canada (1995), the American Conference of Governmental Industrial Hy- gienists (ACGIH, 1999), the US Environmental Protection Agency (EPA, 2001), and the American Industrial Hygiene Association (AIHA, 2001). CDC also offers advice based on the Occupational Safety and Health Administra- tion, EPA, and New York City 2005 revised guidance (Brandt et al., 2006).

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147 DAMPNESS, MOISTURE, AND FLOODING The summary advice of those authors and organizations is straightfor- ward. Quoting from Damp Indoor Spaces and Health (IOM, 2004): • omes and other buildings should be designed, operated, and main- H tained to prevent water intrusion and excessive moisture accumulation when possible. When water intrusion or moisture accumulation is discovered, the sources should be identified and eliminated as soon as practicable to reduce the possibility of problematic microbial growth and building material degradation. • hen microbial contamination is found, it should be eliminated by W means that limit the possibility of recurrence and limit exposure of oc- cupants and persons conducting the remediation. Operationalizing the advice, however, is difficult. The 2004 IOM re- port committee concluded that “the prevalence and nature of dampness problems suggest that what is known about their causes and prevention is not consistently applied in building design, construction, maintenance, and use.” Buildings are a complex combination of foundation, structure elements, and interior components, including insulation, plumbing, HVAC, and ancillary systems. Changes in one may affect the function of others in ways that are difficult to anticipate. Climate change may complicate dampness prevention planning and re- sponses. Buildings are—at least ideally—designed to operate in a particular set of outdoor environmental conditions. Local building codes are predi- cated on those conditions, specifying resistance against projected weather extremes. Building-insurance interests base their premium calculations (and their economic viability) on assumptions regarding the ability of the struc- tures that they underwrite to survive such extremes. If climatic conditions in a particular area change—for example, if there are more severe or more frequent episodes of intense precipitation—buildings constructed under existing codes and designed to operate under previously existing conditions may fail to perform as designed under the new conditions. That suggests that careful consideration must be given to revising building codes and practices to anticipate future climatic conditions and to taking a coordi- nated approach to addressing risks. CONCLUSIONS On the basis of its review of the papers, reports, and other information presented in this chapter, the committee has reached the following conclu- sions regarding the health effects of alterations in IEQ due to dampness and flooding:

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148 CLIMATE CHANGE, THE INDOOR ENVIRONMENT, AND HEALTH • S tudies reviewed in the 2004 IOM report Damp Indoor Spaces and Health and confirmed by research indicate that o Excessive indoor dampness is a determinant of the presence or source strength of several potentially problematic exposures. Damp indoor environments favor house-dust mites and the growth of mold and other microbial agents, standing water supports cockroach and rodent infestations, and excessive mois- ture may initiate or enhance chemical emissions from building materials and furnishings. o Damp indoor environments are associated with the initiation or exacerbation of a number of respiratory ailments. • Extreme weather and flooding events that penetrate buildings— which may become more frequent or severe in the future—increase the number of people at risk for health conditions related to standing water, wet building materials, and sustained high indoor humidity. • Dampness problems in buildings can be difficult to anticipate. The information needed to minimize the risk of their occurrence or their severity is available but is not being consistently applied. • Current buildings and building design, construction, operation, and maintenance practices may not be appropriate for managing indoor dampness or flooding problems due to outdoor environmental conditions that could result from climate change. New, flexible ap- proaches that anticipate potential problems and take measures to prevent them or minimize their adverse consequences are needed. REFERENCES ACGIH (American Conference of Governmental Industrial Hygienists). 1999. Bioaerosols— Assessment and control. Cincinnati, Ohio. AIHA (American Industrial Hygiene Association). 1996. Field guide for the determination of biological contaminants in environmental samples. Fairfax, VA: AIHA Press. AIHA. 2001. Report of the Microbial Task Force. Fairfax, VA: AIHA Press. Akinbami L. 2011. Asthma prevalence, health care use, and mortality: United States, 2005- 2009. National Health Statistics Reports 32. ASHRAE (American Society of Heating, Refrigerating and Air-Conditioning Engineers). 2009. Indoor air quality guide: The best practices for design, construction and commissioning. Atlanta, GA: ASHRAE. Anderson SE, Wells JR, Fedorowicz A, Butterworth LF, Meade BJ, Munson AE. 2007. Evalu- ation of the contact and respiratory sensitization potential of volatile organic compounds generated by simulated indoor air chemistry. Toxicological Sciences 97:355-363. Anderson SE, Jackson LG, Franko J, Wells JR. 2010. Evaluation of dicarbonyls generated in a simulated indoor air environment using an in vitro exposure system. Toxicological Sciences 115:453-461.

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