Walking into a modern building can sometimes be compared to placing your head inside a plastic bag that is filled with toxic fumes.”
Founder, Healthy House Institute
We all face a variety of risks to our health as we go about our day-to-day lives. Driving in cars, flying in airplanes, engaging in recreational activities, and being exposed to environmental pollutants all pose varying degrees of risk. Some risks are simply unavoidable. Some we choose to accept because to do otherwise would restrict our ability to lead our lives the way we want. Some are risks we might decide to avoid if we had the opportunity to make informed choices. Indoor air pollution and exposure to hazardous substances in the home are risks we can do something about.
In the last several years, a growing body of scientific evidence has indicated that the air within homes and other buildings can be more seriously polluted than the outdoor air in even the largest and most industrialized cities. Other research indicates that people spend approximately 90% of their time indoors. Thus, for many people, the risks to health from exposure to indoor air pollution may be greater than risks from outdoor pollution.
In addition, people exposed to indoor air pollutants for the longest periods are often those most susceptible to their effects. Such groups include the young, the elderly, and the chronically ill, especially those suffering from respiratory or cardiovascular disease . Top of PageIndoor Air Pollution
Numerous forms of indoor air pollution are possible in the modern home. Air pollutant levels in the home increase if not enough outdoor air is brought in to dilute emissions from indoor sources and to carry indoor air pollutants out of the home. In addition, high temperature and humidity levels can increase the concentration of some pollutants. Indoor pollutants can be placed into two groups, biologic and chemical.
Biologic pollutants include bacteria, molds, viruses, animal dander, cat saliva, dust mites, cockroaches, and pollen. These biologic pollutants can be related to some serious health effects. Some biologic pollutants, such as measles, chickenpox, and influenza are transmitted through the air. However, the first two are now preventable with vaccines. Influenza virus transmission, although vaccines have been developed, still remains of concern in crowded indoor conditions and can be affected by ventilation levels in the home.
Common pollutants, such as pollen, originate from plants and can elicit symptoms such as sneezing, watery eyes, coughing, shortness of breath, dizziness, lethargy, fever, and digestive problems. Allergic reactions are the result of repeated exposure and immunologic sensitization to particular biologic allergens.
Although pollen allergies can be bothersome, asthmatic responses to pollutants can be life threatening. Asthma is a chronic disease of the airways that causes recurrent and distressing episodes of wheezing, breathlessness, chest tightness, and coughing . Asthma can be broken down into two groups based on the causes of an attack: extrinsic (allergic) and intrinsic (nonallergic). Most people with asthma do not fall neatly into either type, but somewhere in between, displaying characteristics of both classifications. Extrinsic asthma has a known cause, such as allergies to dust mites, various pollens, grass or weeds, or pet danders. Individuals with extrinsic asthma produce an excess amount of antibodies when exposed to triggers. Intrinsic asthma has a known cause, but the connection between the cause and the symptoms is not clearly understood. There is no antibody hypersensitivity in intrinsic asthma. Intrinsic asthma usually starts in adulthood without a strong family history of asthma. Some of the known triggers of intrinsic asthma are infections, such as cold and flu viruses, exercise and cold air, industrial and occupational pollutants, food additives and preservatives, drugs such as aspirin, and emotional stress. Asthma is more common in children than in adults, with nearly 1 of every 13 school-age children having asthma . Low-income African-Americans and certain Hispanic populations suffer disproportionately, with urban inner cities having particularly severe problems. The impact on neighborhoods, school systems, and health care facilities from asthma is severe because one-third of all pediatric emergency room visits are due to asthma, and it is the fourth most prominent cause of physician office visits. Additionally, it is the leading cause of school absenteeism—14 million school days lost each year—from chronic illness .
The U.S. population, on the average, spends as much as 90% of its time indoors. Consequently, allergens and irritants from the indoor environment may play a significant role in triggering asthma episodes. A number of indoor environmental asthma triggers are biologic pollutants. These can include rodents (discussed in Chapter 4), cockroaches, mites, and mold.
The droppings, body parts, and saliva of cockroaches can be asthma triggers. Cockroaches are commonly found in crowded cities and in the southern United States. Allergens contained in the feces and saliva of cockroaches can cause allergic reactions or trigger asthma symptoms. A national study by Crain et al.  of 994 inner-city allergic children from seven U.S. cities revealed that cockroaches were reported in 58% of the homes. The Community Environmental Health Resource Center reports that cockroach debris, such as body parts and old shells, trigger asthma attacks in individuals who are sensitized to cockroach allergen . Special attention to cleaning must be a priority after eliminating the presence of cockroaches to get rid of the presence of any allergens left that can be asthma triggers.
House Dust Mites
Another group of arthropods linked to asthma is house dust mites. In 1921, a link was suggested between asthmatic symptoms and house dust, but it was not until 1964 that investigators suggested that a mite could be responsible. Further investigation linked a number of mite species to the allergen response and revealed that humid homes have more mites and, subsequently, more allergens. In addition, researchers established that fecal pellets deposited by the mites accumulated in home fabrics and could become airborne via domestic activities such as vacuuming and dusting, resulting in inhalation by the inhabitants of the home. House dust mites are distributed worldwide, with a minimum of 13 species identified from house dust. The two most common in the United States are the North American house dust mite ( Dermatophagoides farinae) and the European house dust mite ( D. pteronyssinus). According to Lyon , house dust mites thrive in homes that provide a source of food and shelter and adequate humidity. Mites prefer relative humidity levels of 70% to 80% and temperatures of 75°F to 80°F (24°C to 27°C). Most mites are found in bedrooms in bedding, where they spend up to a third of their lives. A typical used mattress may have from 100,000 to 10 million mites in it. In addition, carpeted floors, especially long, loose pile carpet, provide a microhabitat for the accumulation of food and moisture for the mite, and also provide protection from removal by vacuuming. The house dust mite’s favorite food is human dander (skin flakes), which are shed at a rate of approximately 0.20 ounces per week.
A good microscope, as well as a trained observer, are imperative in detecting mites. House dust mites also can be detected using diagnostic tests that measure the presence and infestation level of mites by combining dust samples collected from various places inside the home with indicator reagents . Assuming the presence of mites, the precautions listed below should be taken if people with asthma are present in the home:
- Use synthetic rather than feather and down pillows.
- Use an approved allergen barrier cover to enclose the top and sides of mattresses and pillows and the base of the bed.
- Use a damp cloth to dust the plastic mattress cover daily.
- Change bedding and vacuum the bed base and mattress weekly.
- Use nylon or cotton cellulose blankets rather than wool blankets.
- Use hot (120°F–130°F [49°C–54°C]) water to wash all bedding, as well as room curtains.
- Eliminate or reduce fabric wall hangings, curtains, and drapes.
- Use wood, tile, linoleum, or vinyl floor covering rather than carpet. If carpet is present, vacuum regularly with a high-efficiency particulate air (HEPA) vacuum or a household vacuum with a microfiltration bag.
- Purchase stuffed toys that are machine washable.
- Use fitted sheets to help reduce the accumulation of human skin on the mattress surface.
HEPA vacuums are now widely available and have also been shown to be effective . A conventional vacuum tends to be inefficient as a control measure and results in a significant increase in airborne dust concentrations, but can be used with multilayer microfiltration collection bags. Another approach to mite control is reducing indoor humidity to below 50% and installing central air conditioning.
Two products are available to treat house dust mites and their allergens. These products contain the active ingredients benzyl benzoate and tannic acid.
According to the U.S. Environmental Protection Agency (EPA) , pets can be significant asthma triggers because of dead skin flakes, urine, feces, saliva, and hair. Proteins in the dander, urine, or saliva of warm-blooded animals can sensitize individuals and lead to allergic reactions or trigger asthmatic episodes. Warm-blooded animals include dogs, cats, birds, and rodents (hamsters, guinea pigs, gerbils, rats, and mice). Numerous strategies, such as the following, can diminish or eliminate animal allergens in the home:
- Eliminate animals from the home.
- Thoroughly clean the home (including floors and walls) after animal removal.
- If pets must remain in the home, reduce pet exposure in sleeping areas. Keep pets away from upholstered furniture, carpeted areas, and stuffed toys, and keep the pets outdoors as much as possible.
However, there is some evidence that pets introduced early into the home may prevent asthma. Several studies have shown that exposure to dogs and cats in the first year of life decreases a child’s chances of developing allergies  and that exposure to cats significantly decreases sensitivity to cats in adulthood . Many other studies have shown a decrease in allergies and asthma among children who grew up on a farm and were around many animals .
People are routinely exposed to more than 200 species of fungi indoors and outdoors . These include moldlike fungi, as well as other fungi such as yeasts and mushrooms. The terms “mold” and “mildew” are nontechnical names commonly used to refer to any fungus that is growing in the indoor environment. Mold colonies may appear cottony, velvety, granular, or leathery, and may be white, gray, black, brown, yellow, greenish, or other colors. Many reproduce via the production and dispersion of spores. They usually feed on dead organic matter and, provided with sufficient moisture, can live off of many materials found in homes, such as wood, cellulose in the paper backing on drywall, insulation, wallpaper, glues used to bond carpet to its backing, and everyday dust and dirt.
Certain molds can cause a variety of adverse human health effects, including allergic reactions and immune responses (e.g., asthma), infectious disease (e.g., histoplasmosis), and toxic effects (e.g., aflatoxin-induced liver cancer from exposure to this mold-produced toxin in food) . A recent Institute of Medicine (IOM) review of the scientific literature found sufficient evidence for an association between exposure to mold or other agents in damp indoor environments and the following conditions: upper respiratory tract symptoms, cough, wheeze, hypersensitivity pneumonitis in susceptible persons, and asthma symptoms in sensitized persons . A previous scientific review was more specific in concluding that sufficient evidence exists to support associations between fungal allergen exposure and asthma exacerbation and upper respiratory disease . Finally, mold toxins can cause direct lung damage leading to pulmonary diseases other than asthma .
The topic of residential mold has received increasing public and media attention over the past decade. Many news stories have focused on problems associated with “toxic mold” or “black mold,” which is often a reference to the toxin-producing mold, Stachybotrys chartarum. This might give the impression that mold problems in homes are more frequent now than in past years; however, no good evidence supports this. Reasons for the increasing attention to this issue include high-visibility lawsuits brought by property owners against builders and developers, scientific controversies regarding the degree to which specific illness outbreaks are mold-induced, and an increase in the cost of homeowner insurance policies due to the increasing number of mold-related claims. Modern construction might be more vulnerable to mold problems because tighter construction makes it more difficult for internally generated water vapor to escape, as well as the widespread use of paper-backed drywall in construction (paper is an excellent medium for mold growth when wet), and the widespread use of carpeting.
Allergic Health Effects. Many molds produce numerous protein or glycoprotein allergens capable of causing allergic reactions in people. These allergens have been measured in spores as well as in other fungal fragments. An estimated 6%–10% of the general population and 15%–50% of those who are genetically susceptible are sensitized to mold allergens . Fifty percent of the 937 children tested in a large multicity asthma study sponsored by the National Institutes of Health showed sensitivity to mold, indicating the importance of mold as an asthma trigger among these children . Molds are thought to play a role in asthma in several ways. Molds produce many potentially allergenic compounds, and molds may play a role in asthma via release of irritants that increase potential for sensitization or release of toxins (mycotoxins) that affect immune response .
Toxics and Irritants. Many molds also produce mycotoxins that can be a health hazard on ingestion, dermal contact, or inhalation . Although common outdoor molds present in ambient air, such as Cladosporium cladosporioides and Alternaria alternata, do not usually produce toxins, many other different mold species do . Genera-producing fungi associated with wet buildings, such as Aspergillus versicolor, Fusarium verticillioides, Penicillium aiurantiorisen, and S. chartarum, can produce potent toxins . A single mold species may produce several different toxins, and a given mycotoxin may be produced by more than one species of fungi. Furthermore, toxin-producing fungi do not necessarily produce mycotoxins under all growth conditions, with production being dependent on the substrate it is metabolizing, temperature, water content, and humidity . Because species of toxin-producing molds generally have a higher water requirement than do common household molds, they tend to thrive only under conditions of chronic and severe water damage . For example, Stachybotrys typically only grows under continuously wet conditions . It has been suggested that very young children may be especially vulnerable to certain mycotoxins [19, 20]. For example, associations have been reported for pulmonary hemorrhage (bleeding lung) deaths in infants and the presence of S. chartarum [21,22,23, 24].
Causes of Mold. Mold growth can be caused by any condition resulting in excess moisture. Common moisture sources include rain leaks (e.g., on roofs and wall joints); surface and groundwater leaks (e.g., poorly designed or clogged rain gutters and footing drains, basement leaks); plumbing leaks; and stagnant water in appliances (e.g., dehumidifiers, dishwashers, refrigerator drip pans, and condensing coils and drip pans in HVAC systems). Moisture problems can also be due to water vapor migration and condensation problems, including uneven indoor temperatures, poor air circulation, soil air entry into basements, contact of humid unconditioned air with cooled interior surfaces, and poor insulation on indoor chilled surfaces (e.g., chilled water lines). Problems can also be caused by the production of excess moisture within homes from humidifiers, unvented clothes dryers, overcrowding, etc. Finished basements are particularly susceptible to mold problems caused by the combination of poorly controlled moisture and mold-supporting materials (e.g., carpet, paper-backed sheetrock) . There is also some evidence that mold spores from damp or wet crawl spaces can be transported through air currents into the upper living quarters. Older, substandard housing low income families can be particularly prone to mold problems because of inadequate maintenance (e.g., inoperable gutters, basement and roof leaks), overcrowding, inadequate insulation, lack of air conditioning, and poor heating. Low interior temperatures (e.g., when one or two rooms are left unheated) result in an increase in the relative humidity, increasing the potential for water to condense on cold surfaces.
Mold Assessment Methods. Mold growth or the potential for mold growth can be detected by visual inspection for active or past microbial growth, detection of musty odors, and inspection for water staining or damage. If it is not possible or practical to inspect a residence, this information can be obtained using occupant questionnaires. Visual observation of mold growth, however, is limited by the fact that fungal elements such as spores are microscopic, and that their presence is often not apparent until growth is extensive and the fact that growth can occur in hidden spaces (e.g., wall cavities, air ducts).
Portable, hand-held moisture meters, for the direct measurement of moisture levels in materials, may also be useful in qualitative home assessments to aid in pinpointing areas of potential biologic growth that may not otherwise be obvious during a visual inspection .
For routine assessments in which the goal is to identify possible mold contamination problems before remediation, it is usually unnecessary to collect and analyze air or settled dust samples for mold analysis because decisions about appropriate intervention strategies can typically be made on the basis of a visual inspection . Also, sampling and analysis costs can be relatively high and the interpretation of results is not straightforward. Air and dust monitoring may, however, be necessary in certain situations, including 1) if an individual has been diagnosed with a disease associated with fungal exposure through inhalation, 2) if it is suspected that the ventilation systems are contaminated, or 3) if the presence of mold is suspected but cannot be identified by a visual inspection or bulk sampling . Generally, indoor environments contain large reservoirs of mold spores in settled dust and contaminated building materials, of which only a relatively small amount is airborne at a given time.
Common methods for sampling for mold growth include bulk sampling techniques, air sampling, and collection of settled dust samples. In bulk sampling, portions of materials with visual or suspected mold growth (e.g., sections of wallboard, pieces of duct lining, carpet segments, or return air filters) are collected and directly examined to determine if mold is growing and to identify the mold species or groups that are present. Surface sampling in mold contamination investigations may also be used when a less destructive technique than bulk sampling is desired. For example, nondestructive samples of mold may be collected using a simple swab or adhesive tape .
Air can also be sampled for mold using pumps that pull air across a filter medium, which traps airborne mold spores and fragments. It is generally recommended that outdoor air samples are collected concurrent with indoor samples for comparison purposes for measurement of baseline ambient air conditions. Indoor contamination can be indicated by indoor mold distributions (both species and concentrations) that differ significantly from the distributions in outdoor samples . Captured mold spores can be examined under a microscope to identify the mold species/groups and determine concentrations or they can be cultured on growth media and the resulting colonies counted and identified. Both techniques require considerable expertise.
Dust sampling involves the collection of settled dust samples (e.g., floor dust) using a vacuum method in which the dust is collected onto a porous filter medium or into a container. The dust is then processed in the laboratory and the mold identified by culturing viable spores.
Mold Standards. No standard numeric guidelines exist for assessing whether mold contamination exists in an area. In the United States, no EPA regulations or standards exist for airborne mold contaminants . Various governmental and private organizations have, however, proposed guidance on the interpretation of fungal measures of environmental media in indoor environments (quantitative limits for fungal concentrations).
Given evidence that young children may be especially vulnerable to certain mycotoxins  and in view of the potential severity or diseases associated with mycotoxin exposure, some organizations support a precautionary approach to limiting mold exposure . For example, the American Academy of Pediatrics recommends that infants under 1 year of age are not exposed at all to chronically moldy, water-damaged environments .
Mold Mitigation. Common intervention methods for addressing mold problems include the following:
- maintaining heating, ventilating, and air conditioning (HVAC) systems;
- changing HVAC filters frequently, as recommended by manufacturer;
- keeping gutters and downspouts in working order and ensuring that they drain water away from the foundation;
- routinely checking, cleaning, and drying drip pans in air conditioners, refrigerators, and dehumidifiers;
- increasing ventilation (e.g., using exhaust fans or open windows to remove humidity when cooking, showering, or using the dishwasher);
- venting clothes dryers to the outside; and
- maintaining an ideal relative humidity level in the home of 40% to 60%.
- locating and removing sources of moisture (controlling dampness and humidity and repairing water leakage problems);
- cleaning or removing mold-contaminated materials;
- removing materials with severe mold growth; and
- using high-efficiency air filters.
Moisture Control. Because one of the most important factors affecting mold growth in homes is moisture level, controlling this factor is crucial in mold abatement strategies. Many simple measures can significantly control moisture, for example maintaining indoor relative humidity at no greater than 40%–60% through the use of dehumidifiers, fixing water leakage problems, increasing ventilation in kitchens and bathrooms by using exhaust fans, venting clothes dryers to the outside, reducing the number of indoor plants, using air conditioning at times of high outdoor humidity, heating all rooms in the winter and adding heating to outside wall closets, sloping surrounding soil away from building foundations, fixing gutters and downspouts, and using a sump pump in basements prone to flooding . Vapor barriers, sump pumps, and aboveground vents can also be installed in crawlspaces to prevent moisture problems .
Removal and Cleaning of Mold-contaminated Materials. Nonporous (e.g., metals, glass, and hard plastics) and semiporous (e.g., wood and concrete) materials contaminated with mold and that are still structurally sound can often be cleaned with bleach-and-water solutions. However, in some cases, the material may not be easily cleaned or may be so severely contaminated that it may have to be removed. It is recommended that porous materials (e.g., ceiling tiles, wallboards, and fabrics) that cannot be cleaned be removed and discarded . In severe cases, clean-up and repair of mold-contaminated buildings may be conducted using methods similar to those used for abatement of other hazardous substances such as asbestos . For example, in situations of extensive colonization (large surface areas greater than 100 square feet or where the material is severely degraded), extreme precautions may be required, including full containment (complete isolation of work area) with critical barriers (airlock and decontamination room) and negative pressurization, personnel trained to handle hazardous wastes, and the use of full-face respirators with HEPA filters, eye protection, and disposable full-body covering .