Comment; Respiratory conditions are the least of the problems from mold-related illnesses
Joseph Pizzorno, ND, Editor in ChiefCopyright and License informationDisclaimerGo to:
Abstract
The concept of mold toxicity being an unrecognized cause of chronic disease has been around the integrative medicine (IM) community for quite some time. Clearly there is considerable interest in the public with a Google search revealing more than half a million hits. In the first part of this editorial, I address the research evaluating this concept for respiratory conditions, the incidence in the population, diagnosis, and intervention. In the second part of my editorial, I will address the far more complicated and controversial nonrespiratory mold-related conditions (tentatively next issue, as I will be attending the SpiritMed Environmental Medicine conference, which is providing a full day on this issue). As usual, I am taking my own fresh look at the concepts and research.
Molds are fungi that grow best in warm, damp, and humid conditions. There are tens of thousands of species that spread and reproduce by making spores that can survive harsh environmental conditions. According to the Centers for Disease Control (CDC), the most common indoor molds are of the Cladosporium, Penicillium, Alternaria, and Aspergillus genera.1 In general, any area with a relative humidity of greater than 80% in the presence of metabolizable organic materials supports their growth. A relative humidity more than 90% is ideal for proliferation. (Note, I am not considering in these 2 editorials the clinical significance of food-born mycotoxins. This came up a quite a bit in my research searches and looks like a good topic for a future editorial.)
Many terms have been used to describe this phenomenon, such as sick building syndrome (SBS). In 2009, the World Health Organization (WHO) published a comprehensive guideline, “Indoor Air Quality: Dampness and Mould.”2 In this 248-page report, the WHO estimated that 10% to 50% of indoor environments in Europe, North America, Australia, India, and Japan have clinically significant mold problems. The percentage is higher in river valleys and coastal areas. Table 1 lists the WHO primary indicators of dampness and microbial growth.
Table 1
The Primary Indicators of Dampness and Microbial Growth
| Condensation on surfaces or in structures such as windowsVisible mold, especially black moldPerceived moldy odorPoorly maintained air conditioning systemsA history of water damage (exterior leaks, wet basement, leaking plumbing) |
Abbreviation: VOC, volatile organic compounds.
The primary clinical indications in the WHO and CDC (discussed later) reports are listed in Table 2 and have been shown to improve with remediation of dampness and eradication of microbial overgrowth in building.
Table 2
Clinical Conditions Indicative of Dampness and Mold
| Common conditionsAllergic rhinitisExacerbation of asthmaRespiratory infectionsCommon symptomsCoughUpper respiratory tract (nasal and throat) symptomsWheezeRare conditionsAllergic alveolitisAllergic fungal sinusitisChronic rhinosinusitisHypersensitivity pneumonitis |
Note that the WHO does not provide any support for the nonrespiratory conditions considered important indicators of mold problems in the integrative medicine (IM) community. Finally, a quote from this report:
Microbial growth may result in greater numbers of spores, cell fragments, allergens, mycotoxins, endotoxins, β-glucans and volatile organic compounds in indoor air. The causative agents of adverse health effects have not been identified conclusively, but an excess level of any of these agents in the indoor environment is a potential health hazard.
I have italicized the key phrase that highlights why this has been such a challenging issue to address quantitatively as the causative agents can be so diverse and clinical effects appear to be highly dependent on individual susceptibility and sensitivity.Go to:
How Dampness Causes Problems
Indoor environments contain a complex mixture of live and dead microorganisms, fragments of dead organisms, toxins, allergens, volatile microbial organic compounds, and other chemicals. Table 3 lists some of the many ways damp building materials can cause the production of toxins. Table 4 lists the kinds of biological and chemical toxins that have been found. This is by no means complete; rather, those included are worst or most prevalent. Finally, Table 5 lists the scientifically accepted physiological effects. It’s strange that only the respiratory effects are considered clinically important.
Table 3
Damp Building Materials Can Cause the Production of Undesirable Organisms and Toxins
| Growth of molds that release biological agents, toxic chemicals, and sporesGrowth of bacteria that release biological agents, toxic chemicals, and sporesProtozoal growthVirus survivalDust mites (arachnids of many different species) proliferationProliferation of rodents and cockroaches that can carry infectious organismsRelease of chemicals and particles from building materials |
Table 4
Partial List the Toxic Agents Found in Dust and Air of Damp Buildings
| AllergensDust mite allergens. Dust mites produce the predominant inhalation allergens in most of the world. Most common are proteases from Dermatophagoides pteronyssinus and Dermatophagoides farinae.Fungal allergens. Typically glycopeptides with enzymatic properties and are typically found in spores, hyphae and fungal fragments. Have the strongest correlation with asthma.Biologicalsβ-glucans. These are proinflammatory, nonallergenic, water-insoluble, structural cell-wall components found in most fungi, some bacteria, most higher plants, and many lower plants.Multiple organic molecules. Examples include endotoxins and ergosterol (yes, vitamin D2) and penicillin G (which would seem likely a problem for patients allergic this class of antibiotics).Mycotoxins. These are metabolites produced by fungi, which can cause a toxic response in animals and human beings, often at very low concentrations. See below for a more complete discussion.MVOC (methane VOC). Several fungi produce volatile metabolites depending on species and substrate.Toxic chemicalsPhthalatesFormaldehydeVOC such as alcohols, aldehydes, ketones, terpenes, esters, aromatic compounds, amines, and sulfur-containing compounds. |
Table 5
Primary Mechanisms for Damp Building Toxicity
| ImmunologyStimulationSuppressionAutoimmunityToxicityNeurotoxicityGenotoxicityReproductive damageInflammation |
Health Effects
Since approximately 2005, a broad international consensus has been reached that mold and dampness in buildings significantly increases disease risk and is a public health hazard. However, the various governmental agencies, such as the Institute of Medicine report commissioned by the CDC and released in 2004, concluded that only conditions considered to have sufficient evidence of causation by mold or damp buildings are respiratory.3 The vast majority of the peer-reviewed published research is on respiratory conditions. The increased risk has been found throughout the population and not limited to those with atopy as was originally thought. Interestingly, the research is supporting that exposure to mold and dampness increases the risk of allergy to other allergens such as house dust mites and pollen, not only fungi, and causes epigenetic modulation that upregulates many inflammatory genes.4 This may help explain the nonrespiratory conditions considered mold-related by the IM community, which will be discussed in my next editorial.
Asthma, Asthma-related and Respiratory Conditions
The research is clear that mold and damp building exposure is a major factor in the asthma epidemic. One study estimated that dampness or mold in houses causes 21% of asthma in the United States, whereas a meta-analysis found a 30% to 50% increase in asthma and asthma-related health problems.5,6 However, the incidence may be much higher. One study of 1300 office workers found that a remarkable 67% of adult-onset asthma started after working in a water-damaged office building.7 The rare condition allergic alveolitis, also known as extrinsic allergic alveolitis and hypersensitivity pneumonitis, is likely primarily due to mold reactivity and has a strong correlation with the use of contaminated air humidifiers. Inhalation fever, also known as toxic pneumonitis, humidifier fever, and organic dust toxic syndrome, also occurs with contaminated humidifiers.
Looking at quite a number of studies, the research is clear: Every patient suffering any kind of chronic respiratory condition—especially those of adult onset—must be fully evaluated for mold/damp building exposure. Included in this list should be also be symptoms such as dyspnea, wheeze, cough, respiratory infections, bronchitis, allergic rhinitis, eczema, vocal cord dysfunction, and upper respiratory tract symptoms. Once a person has become sensitized, they become much more reactive to even low to modest exposure. The symptom and disease associations are far stronger when dust levels rather than air levels of mold products are measured. This seems logical as air levels are much more likely to vary dramatically while dust averages exposure over time.Go to:
Diagnosis/Assessment
Basically, the clinician needs to determine if the patient has a high likelihood of a condition caused by building dampness, they spend time in a home or office building with dampness problems, or if mold is obviously present in their environment according to visuals or odor.
The level of humidity in the various parts of the building can be easily measured by a variety of readily available and inexpensive monitors. I have measured various areas in my own home and can affirm that on rainy days in Seattle, even my modern well-kept house has many areas conducive to mold growth. I found one area of my home with 88% humidity, which had black mold that we had to remove. In fact, to fix the problem we had to reroute the plumbing and totally replace all the plaster board in the area.
A more sophisticated and clinically validated method is to directly measure the contaminants in the air, on surfaces, or in dust. There are basically 4 methods: culture, nonculture, chemical assays for key toxic molecules, and immunoassays. The obvious advantage of culturing is being able to definitively determine the organisms involved. The disadvantages are delay and cost, but probably most problematic is that many are difficult to culture and there is poor reproducibility between the several different collection and culturing protocols. The nonculture protocols basically count the number of particles, organisms, and others caught by the collection tools, such as air filtration or liquid capturing. Their big advantage is quantification but suffer from poor differentiation. The latter can be helped with various staining methods. A typical stain is lactophenol blue for fungal spores. The chemical assay depends on the toxins chosen to evaluate. Typical assessment methodologies include polymerase chain reaction (PCR), immunoassays, gas chromatography, high-pressure liquid chromatography, and mass spectrometry. In general, immunoassays are used to determine allergen types. Regardless of the methodology used, in general dust samples are more sensitive and accurate measures than air samples with better clinical correlation.
According to a local mold testing service, an onsite inspection typically costs $289. They visually check typical locations for water damage, mold growth, and others, and they take samples as appropriate. Nonculture, microscopic evaluation mold analysis costs $100 per sample and evaluations of biologicals (pollens, insect fragments, etc) adds another $175. Obviously, it’s not inexpensive, but if the core cause of an unresolved clinical problem can be identified and treated, it’s well worth the investment. Table 6 shows the several national associations that credential individuals and companies and the certifications.
Table 6
Certifications and Certification Organizations
| ACAC – American Council of Accredited CertificationsAIHA – American Industrial Hygiene AssociationCMC – certified mold consultantCIEC – certified indoor environmental consultantCIH – certified industrial hygienist w/mold experience |
Clinical Evaluation
Table 7 lists alphabetically the conditions and symptoms that should alert a clinician of a mold/damp building problem. I think these can be simply summed up as any chronic, unexplained respiratory tract problem.
Table 7
Diseases and Symptoms Caused or Aggravated by Mold/Damp Buildings
| Diseases | Symptoms |
|---|---|
| Allergic rhinitis | Bronchitis |
| Allergic alveolitis (hypersensitivity pneumonitis) | Cough |
| Asthma | Dyspnea |
| Chronic respiratory infections | Hoarseness |
| Eczema | Vocal cord dysfunction |
| Inhalation fever (toxic pneumonitis, humidifier fever and organic dust toxic syndrome) | Wheeze |
A number of laboratories run a wide range of tests that can help with diagnosis. For example, LabCore responds with 58 tests for the search term mold. These include mold identification through DNA and culturing, antibodies to specific molds, various inflammatory markers, and others.Go to:
Intervention
Decrease Exposure
Of course, we have to start by dealing with the causes, which starts with decreasing exposure. There is no substitute for fixing with the foundational causes: typically excessive building humidity from poor design or water damage, inadequate ventilation, and contaminated air conditioning vents. Addressing these is obviously beyond the scope of this journal and will require professional assistance. Nonetheless, there is not much point in trying to only treat the patient when the problem is almost entirely due to the environment. In many ways, this is a problem of civilization.
Several studies in both children and adults have objectively assessed the clinical effects of addressing building moisture. An excellent review paper evaluated 8 studies (6538 participants); 2 randomized controlled trials (RCTs) (294 participants), 1 cluster randomized controlled trial (cRCT) (4407 participants), and 5 controlled before-after (CBA) studies (1837 participants) for the effects of building remediation. They found moderate-quality evidence in adults that repairing houses decreased asthma-related symptoms (odds ratio [OR], 0.64) and respiratory infections (OR, 0.57). For children, they reported moderate-quality evidence for reduction of the number of acute care visits (mean difference, −0.45).8
Obviously, complete care is more than building remediation, but it needs to start there. I believe reasonable to expect that dealing with building moisture will facilitate the efficacy of our normal dietary, allergen control, nutritional, and herbal medicine treatments for asthma and other chronic respiratory conditions.Go to:
Conclusion
Considering the remarkable diversity of allergenic, biological, and organic and inorganic molecules released into the air and concentrated in the dust of damp buildings and that as many as 50% of buildings have moisture problems, harmful physiological effects are certain. What is uncertain is which patients are susceptible, which conditions are most predictive, and the optimal interventions.
Without doubt, every patient with any kind of chronic respiratory condition, especially asthma, must be evaluated for damp building exposure. Frankly, this is a much bigger clinical problem than I had realized before looking at the voluminous research in this area.Go to:
In This Issue
There is simply no better clinical care than treating the whole person, not only their biochemistry. This is well illustrated by the original research of Hannah Chatwin, mclinpsych; Peta Stapleton, phd; Brett Porter, eft; Sharon Devine, mclinpsych; and Terri Sheldon, ba(hons). They show in this pilot study that cognitive behavioral therapy and emotional freedom techniques are effective in reducing depression and anxiety without drugs—no matter how natural. Also, as editor in chief, I must admit to being delighted by the growing interest in IMCJ by the international research community.
The need to address the whole person is well demonstrated by the remarkable work of my friend James Gordon, md. As documented in the interview by managing editor, Craig Gustafson, he has worked tirelessly worldwide to address the health effects of serous stress. His work has shown in groups and individuals that addressing the emotional side of posttraumatic stress disorder (PTSD) is critical for health and recovery. His work and training programs are quite remarkable.
I suspect few readers realize that taking care of patients with neurodegenerative disease now costs more than patients with cancer or heart disease. Associate editor, Jeffrey Bland, phd, provides us a fascinating article on dietary and environmental causes. These range from nutrient deficiencies, to environmental toxins to genetic polymorphisms affecting susceptibility. The neuro-degenerative disease epidemic is quite worrisome.
Addressing MTHFT polymorphisms in our patients is turning out to be much more complicated than expected. The interesting case report by Shanna Anderson, ba; Jacob Panka, ba; Robin Rakobitsch, ba; Kaitlin Tyre, bs; and Kerry Pulliam, md, illustrates this quite effectively. To their discussion, I suggest considering the impact of catechol-O-methyltransferase (COMT) polymorphisms. I suspect this may explain the substantial benefit they found with S-adenosyl methionine (SAMe) supplementation.
I am so happy that John Weeks has returned to Seattle as I sorely missed our provocative and wide-ranging quarterly breakfast conversations. I very much appreciate his documentation of the disproportionate impact of the very small profession of naturopathic medicine in the advancement of this medicine. His documentation of the growing acceptance of how IM (by all its name) is changing health care is very important.
I love when I crack up before the end of the first paragraph of Bill Benda, md’s BackTalk. Seems such a great way to balance out the seriousness of our typical articles on suffering and disease. Bill, someday I hope you compile your BackTalks into a book about life.
Joseph Pizzorno, nd, Editor in Chief
- COVID UPDATE: What is the truth? - 2022-11-08
- Pathologist Speaks Out About COVID Jab Effects - 2022-07-04
- A Massive Spike in Disability is Most Likely Due to a Wave of Vaccine Injuries - 2022-06-30
