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Pediatric Environmental Health
Pediatric Environmental Health
This educational module was produced by Rose Goldman, MD, MPH and Alan
This educational module was produced by Rose Goldman, MD, MPH and Alan
Talk Objectives
Talk Objectives
Case: 14 month old with multiple respiratory illnesses
Case: 14 month old with multiple respiratory illnesses
Photo courtesy Alan Woolf, MD, MPH
Photo courtesy Alan Woolf, MD, MPH
Pathogenesis of environmental & toxic injury
Pathogenesis of environmental & toxic injury
Building-Related Medical Illness
Building-Related Medical Illness
What are some of the Major Indoor Air Pollutants
What are some of the Major Indoor Air Pollutants
Typical Damp Environment-Related Health Complaints
Typical Damp Environment-Related Health Complaints
Risk Factors: Children
Risk Factors: Children
Risk Factors: childhood illness from poor indoor air quality and
Risk Factors: childhood illness from poor indoor air quality and
Back to the case
Back to the case
Biological Agents Growing on Damp Indoor Spaces
Biological Agents Growing on Damp Indoor Spaces
Respiratory Illnesses + Damp Environments
Respiratory Illnesses + Damp Environments
Institute Of Medicine: Damp Spaces
Institute Of Medicine: Damp Spaces
IOM Report: Damp Spaces
IOM Report: Damp Spaces
Respirable Particles
Respirable Particles
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Case: 14 month old with multiple respiratory illnesses
Case: 14 month old with multiple respiratory illnesses
Case: 14 month old with multiple respiratory illnesses
Case: 14 month old with multiple respiratory illnesses
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Allergic and Hypersensitivity Reactions
Allergic and Hypersensitivity Reactions
Uncommon Allergic and Hypersensitivity syndromes
Uncommon Allergic and Hypersensitivity syndromes
Hypersensitivity Pneumonitis
Hypersensitivity Pneumonitis
Allergy Assessment
Allergy Assessment
The familys discovery
The familys discovery
Black mold in a newly constructed home
Black mold in a newly constructed home
Photo courtesy Alan Woolf, MD, MPH
Photo courtesy Alan Woolf, MD, MPH
molds are everywhere
molds are everywhere
Boston Globe  06/14/03
Boston Globe 06/14/03
Flooding from Katrina
Flooding from Katrina
Types of indoor molds commonly associated with adverse health effects
Types of indoor molds commonly associated with adverse health effects
What about the fathers complaints of cough and headache
What about the fathers complaints of cough and headache
Differential diagnosis considerations of cough & headache in an adult
Differential diagnosis considerations of cough & headache in an adult
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Case Outcomes
Case Outcomes
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Pathogenesis of injury from molds & damp spaces
Examples of Mycotoxins
Examples of Mycotoxins
Poisoning related to mycotoxins
Poisoning related to mycotoxins
STACHYBOTRYS
STACHYBOTRYS
Stachybotrys chartarum Kuhn DM, Ghannoum MA
Stachybotrys chartarum Kuhn DM, Ghannoum MA
Pathogenesis of infection from molds
Pathogenesis of infection from molds
Fungal Pathogens
Fungal Pathogens
Visual Assessment - Environment
Visual Assessment - Environment
Assessment of possible mold-related illness
Assessment of possible mold-related illness
Indoor airborne fungi levels
Indoor airborne fungi levels
Examples of seasonal total mold counts in the U.S
Examples of seasonal total mold counts in the U.S
Limitations of Testing
Limitations of Testing
Management & Prevention
Management & Prevention
Hazard Reduction
Hazard Reduction
Summary
Summary
Resources: Mold-Related Illness
Resources: Mold-Related Illness

: Pediatric Environmental Health. : Jenny. : Pediatric Environmental Health.ppt. zip-: 4274 .

Pediatric Environmental Health

Pediatric Environmental Health.ppt
1 Pediatric Environmental Health

Pediatric Environmental Health

Health Effects of Indoor Mold Exposure

2 This educational module was produced by Rose Goldman, MD, MPH and Alan

This educational module was produced by Rose Goldman, MD, MPH and Alan

Woolf, MD, MPH for The University of Texas Health Science Center at San Antonio (UTHSCSA) Environmental Medicine Education Program and South Texas Environmental Education and Research Program (STEER-San Antonio/Laredo/Harlingen,Texas) Administrative support was provided by the Association of Occupational and Environmental Clinics through funding to UTHSCSA by the Agency for Toxic Substances and Disease Registry (ATSDR), U.S. Department of Health and Human Services. Use of this program must include acknowledgement of the authors, UTHSCSA and the funding support. For information about other educational modules contact the UTHSCSA STEER office, Mail Code 7796, 7703 Floyd Curl Drive, San Antonio, Texas 78229-3900,(210)567-7407.

3 Talk Objectives

Talk Objectives

The participant will Understand the pathogenesis of environment-related health problems Appreciate the taxonomy and regional variation of molds Appreciate the relationship between molds and other microbial overgrowth in a damp space Know how to assess the patient with health complaints related to living in a damp space Know how to assess the environment of a patient with damp space-related complaints Be able to cite aspects of mold clean-up and prevention Know how to access resources for further information

Photos courtesy: EPA

4 Case: 14 month old with multiple respiratory illnesses

Case: 14 month old with multiple respiratory illnesses

Part 1

2 previous episodes bronchiolitis 12 visits to local physician 2 episodes (1 hospitalization) for pneumonia Father has chronic cough of 2- months duration and complains of headaches. No fever but some greenish nasal discharge. Parents think that mold in their newly built home in this suburban community is the cause Here is the community

5 Photo courtesy Alan Woolf, MD, MPH

Photo courtesy Alan Woolf, MD, MPH

6 Pathogenesis of environmental & toxic injury

Pathogenesis of environmental & toxic injury

Biologically Effective Dose

Biological Uptake

Target Organ Contact

Absorption Distribution Metabolism Excretion

Biologic Change

Clinical Disease

Contaminated Environment

Repair Threshold

7 Building-Related Medical Illness

Building-Related Medical Illness

Building-Related Medical Illness

Specific Indoor Air Quality Problems

Non-specific sick building syndrome

Allergic

Non-Allergic

8 What are some of the Major Indoor Air Pollutants

What are some of the Major Indoor Air Pollutants

Respirable particles Oxides of nitrogen Carbon monoxide Volatile Organic Compounds (VOCs) Radon and radon daughters Asbestos fibers Toxic dusts (lead) Environmental tobacco smoke Biologic Agents (eg mold, endotoxin) and indoor allergens (mites)

9 Typical Damp Environment-Related Health Complaints

Typical Damp Environment-Related Health Complaints

Headache Fatigue Light headedness Eye and nose irritation Cough Wheezing, exacerbation asthma Skin itching and rashes

10 Risk Factors: Children

Risk Factors: Children

Which children are susceptible to inhaled exposures? Why kids versus adults? Where besides the home would you look for environmental contaminants affecting children?

11 Risk Factors: childhood illness from poor indoor air quality and

Risk Factors: childhood illness from poor indoor air quality and

dampness-related effects

PHYSIOLOGY Closer to ground-level toxins Higher minute ventilation DEVELOPMENTAL Pulmonary system Immune system Genetic SUSCEPTIBILITY Prematurity? Frequent wheezing, prior bronchiolitis Chronic respiratory illness (e.g. cystic fibrosis) OTHER ENVIRONMENTS Indoor air quality problems in school, preschool or daycare

12 Back to the case

Back to the case

This was a new home. There was no evidence for Dusty environment Carbon monoxide (detectors in place) Oxides of nitrogen Radon Water intrusion Asbestos Lead Parents denied any exposure to Environmental tobacco smoke Use of solvents or other VOCs

13 Biological Agents Growing on Damp Indoor Spaces

Biological Agents Growing on Damp Indoor Spaces

Fungi Bacteria Dust mite Cockroach

Picture courtesy: John Martyny, PhD - EPA

14 Respiratory Illnesses + Damp Environments

Respiratory Illnesses + Damp Environments

Asthma, wheezing, cough and phlegm associated with residing in damp or water-damaged homes. Irritant related nasal, eye, throat irritation Dampness also associated with cockroach and mite infestation, bacterial growth (bacterial endotoxins), biofilms

Photo courtesy: EPA

15 Institute Of Medicine: Damp Spaces

Institute Of Medicine: Damp Spaces

Sufficient Evidence - upper respiratory tract symptoms, cough, wheeze, asthma in sensitized person Limited evidence - dyspnea, lower tract illness in otherwise healthy person, asthma development

16 IOM Report: Damp Spaces

IOM Report: Damp Spaces

Inadequate or insufficient evidence: Airflow obstruction, COPD Acute idiopathic pulmonary hem. in infants GI tract problems Neuropsychiatric symptoms, fatigue Reproductive effects Rheumatologic and other immune diseases

17 Respirable Particles

Respirable Particles

About 6000 liters of air exchange per day for an adult Smallest particles reach alveoli Some particles stimulate macrophage inflammatory response Water soluble chemicals cause proximal irritation, less deposition distally

From chapter 16, Clinical Pulmonary Toxicology author Lee S. Newman, in Sullivan JB and Krieger GRClinical Environmental Health and Toxic

18 Pathogenesis of injury from molds & damp spaces

Pathogenesis of injury from molds & damp spaces

Allergy

Irritant

Infection

Mycotoxin

Mold & Damp Spaces

19 Case: 14 month old with multiple respiratory illnesses

Case: 14 month old with multiple respiratory illnesses

Part 2

2 previous episodes bronchiolitis 12 visits to local MD 2 episodes (1 hospitalization) for pneumonia Father has chronic cough of 2- months duration and complains of headaches What is in your differential diagnosis?

20 Case: 14 month old with multiple respiratory illnesses

Case: 14 month old with multiple respiratory illnesses

Part 3

Pediatricians preliminary diagnosis = asthma

21 Pathogenesis of injury from molds & damp spaces

Pathogenesis of injury from molds & damp spaces

Allergy

Hypersensitivity Pneumonia

Rhinitis

Asthma

rashes

Mold & Damp Spaces

ABPA

22 Allergic and Hypersensitivity Reactions

Allergic and Hypersensitivity Reactions

About 10% of the population has allergic antibodies to fungal antigens, and 5% have clinical illness Outdoor molds more abundant and important in airway allergic disease Allergic rhinitis (hay fever) or asthma Atopic individuals: mast cell degranulation, IgE antibodies (immediate hypersensitivity) Indoor common molds: Penicillium, Aspergillus Outdoor: Cladosporium, Alternaria (but can also come indoors)

23 Uncommon Allergic and Hypersensitivity syndromes

Uncommon Allergic and Hypersensitivity syndromes

Allergic bronchopulmonary aspergillosis (ABPA)-growth of aspergillus in allergic persons, or those with cystic fibrosis, with airway damage from previous illnesses Allergic bronchopulmonary mycosis Allergic Fungal Sinusitis (AFS)-Aspergillus, Curvularia Specific criteria for ABPA and AFS Exposure to ubiquitous organisms-no link to specific exposures at home or school

24 Hypersensitivity Pneumonitis

Hypersensitivity Pneumonitis

Rare, exposures (usually occupational) to very high concentrations of fungal (or other) proteins High levels of IgG proteins-detected in precipitin tests or gel diffusion (BUT can have +IgG ab, no disease) Cell-mediated and humoral immune reactivity-delayed intense local reactions Examples in humidifier and HVACs-thermophilic Actinomyces (filamentous bacteria)

25 Allergy Assessment

Allergy Assessment

Blood count, white cell count, % eosinophils Nasal eosinophils Immune competency: Ig levels, IgE Sweat test Chest x-ray RAST testing (Sensitivity testing) (Pulmonary function tests) (Provocative testing) () reserved for older patients

26 The familys discovery

The familys discovery

Attic had no fan and very small soffets It was a rainy, wet spring following the homes construction The builder had used improperly cured green plywood

27 Black mold in a newly constructed home

Black mold in a newly constructed home

Photo courtesy Alan Woolf, MD, MPH

28 Photo courtesy Alan Woolf, MD, MPH

Photo courtesy Alan Woolf, MD, MPH

29 molds are everywhere

molds are everywhere

Photos courtesy: Rose Goldman, MD, MPH

30 Boston Globe  06/14/03

Boston Globe 06/14/03

31 Flooding from Katrina

Flooding from Katrina

32 Types of indoor molds commonly associated with adverse health effects

Types of indoor molds commonly associated with adverse health effects

Alternaria most common allergen Aspergillus (A. fumigatus, flavus, niger) 175 species, including 16 known human pathogens; filamentous, some strains mycotoxin-producing Penicillium 200 species, indoors, allergenic (hypersensitivity pneumonia, allergic alveolitis, keratitis, otomycosis, penicilliosis) Stachybotrys atra thrives on cellulose (e.g. sheetrock, wallpaper, paper-backed gypsum, ceiling tiles, insulation), causes dermatitis, rhinitis, nose bleeds, cold symptoms, malaise Cladisporium ubiquitous, breaks down cellulose, pectin, lignin, buoyant spores

Photos courtesy John Martyny, PhD - EPA

33 What about the fathers complaints of cough and headache

What about the fathers complaints of cough and headache

What other information do you need to know about his illness?

34 Differential diagnosis considerations of cough & headache in an adult

Differential diagnosis considerations of cough & headache in an adult

Pneumonia Chronic Bronchitis Cough-Equivalent Asthma Gastroesophageal reflux

Migraine Tension Headache Dental abscess Sinusitis

35 Pathogenesis of injury from molds & damp spaces

Pathogenesis of injury from molds & damp spaces

Allergy

Infection

Irritant

Mycotoxin

Mold & Damp Spaces

Immuno Compromised

36 Case Outcomes

Case Outcomes

Parents relocated to grandparents home in the next town No further health complaints: child or father Family successfully sued builder for remediation This outcome does not prove that mold caused the health complaints For example, airborne and dust-laden endotoxin from bacteria,volatile organic compounds associated with microbial overgrowth, dust mite or cockroach antigens, or airborne particulates might also have played causative roles

37 Pathogenesis of injury from molds & damp spaces

Pathogenesis of injury from molds & damp spaces

Irritant: direct or VOC mediated

Mold & Damp Spaces

Cough, wheeze

Eye, nose, throat symptoms

38 Pathogenesis of injury from molds & damp spaces

Pathogenesis of injury from molds & damp spaces

Mycotoxin

Infantile pulmonary Hemorrhage?

Pneumonia

Mold & Damp Spaces

39 Examples of Mycotoxins

Examples of Mycotoxins

Aflatoxin Cyclochloritine Ethanol Griseofulvin Ipomeamarone Luteoskyrin Ochratoxin Sporidesmin Sterigmatocystin Tetracycline

Photo courtesy: Terry Brennan - EPA

40 Poisoning related to mycotoxins

Poisoning related to mycotoxins

Toxigenic species do not always produce toxins Mycotoxins: usually large, non-volatile molecules that do not off-gas or pass through walls Ingestion of moldy foods (e.g. aflatoxin in grains produces hepatitis & hepatocarcinoma) Stachybotrys species produce trichothecenes Stachybotrys-associated infantile pulmonary hemorrhage

41 STACHYBOTRYS

STACHYBOTRYS

Greenish black, saprophytic, grows well on cellulose Produces spores in a slimy, mucilaginous mass Some species produce trichothecenes Controversy over 10 cases infantile pulmonary hemorrhage in Cleveland, Ohio

Photo courtesy EPA

42 Stachybotrys chartarum Kuhn DM, Ghannoum MA

Stachybotrys chartarum Kuhn DM, Ghannoum MA

Clin Microbiol Rev 2003; 16:144-72

Is there illness found with building associated mycotoxins produced by Stachybotrys , or toxic mold? Acute pulmonary hemorrhage in infants in room with Stachybotrys-?related For toxicity: need high exposure - What is a toxic dose? Could it occur in a typical indoor environments current human studies uniformly suffer from significant methodological flaws, making their findings inconclusivehave not found supportive evidence for serious illness due to Stachybotrys exposure...

43 Pathogenesis of infection from molds

Pathogenesis of infection from molds

Infection

pneumonia

ABPA

Sinusitis

Mold & Damp Spaces

Immuno Compromised

Skin & nail infections

other systemic infection

44 Fungal Pathogens

Fungal Pathogens

Fungal Pathogens - regional, often do not grow indoors Candida - ubiquitous Cryptococcus - associated with bird droppings Histoplasma - (bats) Ohio valley Coccidioides - Southwestern U.S.

45 Visual Assessment - Environment

Visual Assessment - Environment

Interior materials: wet carpet, insulation Building materials: wet wood, wallboard, ceiling tiles Furnishings: damp fleecy furnishings Heating, Ventilation, Air Conditioning (HVAC): condensate pans, moist dirty ductwork Pipes, Drainage: clogged drains, wet traps, leaking water pipes, wet pipe wrappings Ventilation: blocked soffets & vents, no fans

Photo courtesy Terry Brennan - EPA

Photo courtesy John Martyny, PhD - EPA

46 Assessment of possible mold-related illness

Assessment of possible mold-related illness

Biological assessment: characterize signs and symptoms confirmatory testing when indicated Environment: visual inspection air samples (spore count, CFU/m3)

Photos courtesy EPA website

47 Indoor airborne fungi levels

Indoor airborne fungi levels

Indoor air levels are a reflection of outdoor levels (estimated at 40%-80% of outdoor levels) with similar rank order species of fungi. Concentrations of fungi in samples not exposed directly to indoor air may not indicate inhalation risk Estimated that 70% of homes have some mold growing behind walls.

Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309

Photo courtesy EPA

48 Examples of seasonal total mold counts in the U.S

Examples of seasonal total mold counts in the U.S

Data from the National Allergy Bureau, American Academy of Allergy, Asthma and Immunology. Pollen and mold counts. Available at: http://www.aaaai.org

Bardana EJ. Immunol Allergy Clin North Am 2003; 23:291-309 Photo: courtesy Rose Goldman, M.D.

49 Limitations of Testing

Limitations of Testing

Airborne spores are usually 4-100 microns diameter Spore counts do not necessarily predict symptoms Not all spores are equally pathologic Spore counts may fluctuate daily, seasonally This is not an exact science!

Photos courtesy John Martyny, PhD EPA website

50 Management & Prevention

Management & Prevention

What do you see in these pictures? What is possibly the composition of the slime? What good & bad practices do you see in the clean-up?

Photo by: Mike Ahlers, CNN

Photo: FEMA, Naumann

51 Hazard Reduction

Hazard Reduction

Environment: Prevent water intrusion, all reused materials dried and visibly mold-free Clean-Up: Proper PPE, Mold disinfectant (hypochlorites) or disposal EPA recommends hiring a professional for mold growths > 10 square feet in size Monitoring Post-occupancy: De-humidification < 60% relative humidity

N-95 respirator

Above photo courtesy Chin Yang

3 photos courtesy Terry Brennan & EPA website

52 Summary

Summary

Mold-related exposures: over-diagnosed, costly, preventable Damp spaces: cause poor health (mold only one of many concerns) Childrens differences: size, physiology, development, behaviors Mechanisms of mold injury: Irritant Allergy Infectious Toxic Common clinical issues: Mold-related illness: diagnosis & medical management Safe environmental clean-up Prevention

53 Resources: Mold-Related Illness

Resources: Mold-Related Illness

Clinical Resources: Occupational & Environmental Clinics; Pediatric Environmental Health Subspecialty Units; AOEC Local & State Health Departments ATSDR & Regional EPA

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