Guidelines on Assessment and Remediation of Fungi in Indoor Environments

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Guidelines on Assessment and Remediation of Fungi in Indoor

Environments

by The New York City Department of Health and Mental Hygiene

http://www.nyc.gov/html/doh/html/epi/moldrpt1.shtml

Executive Summary On May 7, 1993, the New York City Department of

Health (DOH), the New York City Human Resources Administration

(HRA), and the Mt. Sinai Occupational Health Clinic convened an

expert panel on Stachybotrys atra in Indoor Environments. The

purpose of the panel was to develop policies for medical and

environmental evaluation and intervention to address Stachybotrys

atra (now known as Stachybotrys chartarum (SC)) contamination. The

original guidelines were developed because of mold growth problems

in several New York City buildings in the early 1990's. This

document revises and expands the original guidelines to include all

fungi (mold). It is based both on a review of the literature

regarding fungi and on comments obtained by a review panel

consisting of experts in the fields of microbiology and health

sciences. It is intended for use by building engineers and

management, but is available for general distribution to anyone

concerned about fungal contamination, such as environmental

consultants, health professionals, or the general public.

We are expanding the guidelines to be inclusive of all fungi for

several reasons:

• Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium,

Trichoderma, and Memnoniella) in addition to SC can produce potent

mycotoxins, some of which are identical to compounds produced by SC.

Mycotoxins are fungal metabolites that have been identified as toxic

agents. For this reason, SC cannot be treated as uniquely toxic in

indoor environments.

• People performing renovations/cleaning of widespread fungal

contamination may be at risk for developing Organic Dust Toxic

Syndrome (ODTS) or Hypersensitivity Pneumonitis (HP). ODTS may occur

after a single heavy exposure to dust contaminated with fungi and

produces flu-like symptoms. It differs from HP in that it is not an

immune-mediated disease and does not require repeated exposures to

the same causative agent. A variety of biological agents may cause

ODTS including common species of fungi. HP may occur after repeated

exposures to an allergen and can result in permanent lung damage.

• Fungi can cause allergic reactions. The most common symptoms are

runny nose, eye irritation, cough, congestion, and aggravation of

asthma.

Fungi are present almost everywhere in indoor and outdoor

environments. The most common symptoms of fungal exposure are runny

nose, eye irritation, cough, congestion, and aggravation of asthma.

Although there is evidence documenting severe health effects of

fungi in humans, most of this evidence is derived from ingestion of

contaminated foods (i.e., grain and peanut products) or occupational

exposures in agricultural settings where inhalation exposures were

very high. With the possible exception of remediation to very

heavily contaminated indoor environments, such high-level exposures

are not expected to occur while performing remedial work.

There have been reports linking health effects in office workers to

offices contaminated with moldy surfaces and in residents of homes

contaminated with fungal growth. Symptoms, such as fatigue,

respiratory ailments, and eye irritation were typically observed in

these cases. Some studies have suggested an association between SC

and pulmonary hemorrhage/hemosiderosis in infants, generally those

less than six months old. Pulmonary hemosiderosis is an uncommon

condition that results from bleeding in the lungs. The cause of this

condition is unknown, but may result from a combination of

environmental contaminants and conditions (e.g., smoking, fungal

contaminants and other bioaerosols, and water-damaged homes), and

currently its association with SC is unproven.

The focus of this guidance document addresses mold contamination of

building components (walls, ventilation systems, support beams,

etc.) that are chronically moist or water damaged. Occupants should

address common household sources of mold, such as mold found in

bathroom tubs or between tiles with household cleaners. Moldy food

(e.g., breads, fruits, etc.) should be discarded.

Building materials supporting fungal growth must be remediated as

rapidly as possible in order to ensure a healthy environment. Repair

of the defects that led to water accumulation (or elevated humidity)

should be conducted in conjunction with or prior to fungal

remediation. Specific methods of assessing and remediating fungal

contamination should be based on the extent of visible contamination

and underlying damage. The simplest and most expedient remediation

that is reasonable, and properly and safely removes fungal

contamination, should be used. Remediation and assessment methods

are described in this document.

The use of respiratory protection, gloves, and eye protection is

recommended. Extensive contamination, particularly if heating,

ventilating, air conditioning (HVAC) systems or large occupied

spaces are involved, should be assessed by an experienced health and

safety professional and remediated by personnel with training and

experience handling environmentally contaminated materials. Lesser

areas of contamination can usually be assessed and remediated by

building maintenance personnel. In order to prevent contamination

from recurring, underlying defects causing moisture buildup and

water damage must be addressed. Effective communication with

building occupants is an essential component of all remedial

efforts.

Fungi in buildings may cause or exacerbate symptoms of allergies

(such as wheezing, chest tightness, shortness of breath, nasal

congestion, and eye irritation), especially in persons who have a

history of allergic diseases (such as asthma and rhinitis).

Individuals with persistent health problems that appear to be

related to fungi or other bioaerosol exposure should see their

physicians for a referral to practitioners who are trained in

occupational/environmental medicine or related specialties and are

knowledgeable about these types of exposures. Decisions about

removing individuals from an affected area must be based on the

results of such medical evaluation, and be made on a case-by-case

basis. Except in cases of widespread fungal contamination that are

linked to illnesses throughout a building, building-wide evacuation

is not indicated.

In summary, prompt remediation of contaminated material and

infrastructure repair is the primary response to fungal

contamination in buildings. Emphasis should be placed on preventing

contamination through proper building and HVAC system maintenance

and prompt repair of water damage.

This document is not a legal mandate and should be used as a

guideline. Currently there are no United States Federal, New York

State, or New York City regulations for evaluating potential health

effects of fungal contamination and remediation. These guidelines

are subject to change as more information regarding fungal

contaminants becomes available.

Introduction On May 7, 1993, the New York City Department of Health

(DOH), the New York City Human Resources Administration (HRA), and

the Mt. Sinai Occupational Health Clinic convened an expert panel on

Stachybotrys atra in Indoor Environments. The purpose of the panel

was to develop policies for medical and environmental evaluation and

intervention to address Stachybotrys atra (now known as Stachybotrys

chartarum (SC)) contamination. The original guidelines were

developed because of mold growth problems in several New York City

buildings in the early 1990's. This document revises and expands the

original guidelines to include all fungi (mold). It is based both on

a review of the literature regarding fungi and on comments obtained

by a review panel consisting of experts in the fields of

microbiology and health sciences. It is intended for use by building

engineers and management, but is available for general distribution

to anyone concerned about fungal contamination, such as

environmental consultants, health professionals, or the general

public.

This document contains a discussion of potential health effects;

medical evaluations; environmental assessments; protocols for

remediation; and a discussion of risk communication strategy. The

guidelines are divided into four sections:

1. Health Issues; 2. Environmental Assessment; 3. Remediation; and

4. Hazard Communication.

We are expanding the guidelines to be inclusive of all fungi for

several reasons:

• Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium,

Trichoderma, and Memnoniella) in addition to SC can produce potent

mycotoxins, some of which are identical to compounds produced by

SC.1, 2, 3, 4 Mycotoxins are fungal metabolites that have been

identified as toxic agents. For this reason, SC cannot be treated as

uniquely toxic in indoor environments.

• People performing renovations/cleaning of widespread fungal

contamination may be at risk for developing Organic Dust Toxic

Syndrome (ODTS) or Hypersensitivity Pneumonitis (HP). ODTS may occur

after a single heavy exposure to dust contaminated with fungi and

produces flu-like symptoms. It differs from HP in that it is not an

immune-mediated disease and does not require repeated exposures to

the same causative agent. A variety of biological agents may cause

ODTS including common species of fungi. HP may occur after repeated

exposures to an allergen and can result in permanent lung damage.5,

6, 7, 8, 9, 10

• Fungi can cause allergic reactions. The most common symptoms are

runny nose, eye irritation, cough, congestion, and aggravation of

asthma.11, 12

Fungi are present almost everywhere in indoor and outdoor

environments. The most common symptoms of fungal exposure are runny

nose, eye irritation, cough, congestion, and aggravation of asthma.

Although there is evidence documenting severe health effects of

fungi in humans, most of this evidence is derived from ingestion of

contaminated foods (i.e., grain and peanut products) or occupational

exposures in agricultural settings where inhalation exposures were

very high.13, 14 With the possible exception of remediation to very

heavily contaminated indoor environments, such high level exposures

are not expected to occur while performing remedial work.15

There have been reports linking health effects in office workers to

offices contaminated with moldy surfaces and in residents of homes

contaminated with fungal growth.12, 16, 17, 18, 19, 20 Symptoms,

such as fatigue, respiratory ailments, and eye irritation were

typically observed in these cases.

Some studies have suggested an association between SC and pulmonary

hemorrhage/hemosiderosis in infants, generally those less than six

months old. Pulmonary hemosiderosis is an uncommon condition that

results from bleeding in the lungs. The cause of this condition is

unknown, but may result from a combination of environmental

contaminants and conditions (e.g., smoking, other microbial

contaminants, and water-damaged homes), and currently its

association with SC is unproven.21, 22, 23

The focus of this guidance document addresses mold contamination of

building components (walls, ventilation systems, support beams,

etc.) that are chronically moist or water damaged. Occupants should

address common household sources of mold, such as mold found in

bathroom tubs or between tiles with household cleaners. Moldy food

(e.g., breads, fruits, etc.) should be discarded.

This document is not a legal mandate and should be used as a

guideline. Currently there are no United States Federal, New York

State, or New York City regulations for evaluating potential health

effects of fungal contamination and remediation. These guidelines

are subject to change as more information regarding fungal

contaminants becomes available.

1. Health Issues 1.1 Health Effects

Inhalation of fungal spores, fragments (parts), or metabolites

(e.g., mycotoxins and volatile organic compounds) from a wide

variety of fungi may lead to or exacerbate immunologic (allergic)

reactions, cause toxic effects, or cause infections.11, 12, 24

There are only a limited number of documented cases of health

problems from indoor exposure to fungi. The intensity of exposure

and health effects seen in studies of fungal exposure in the indoor

environment was typically much less severe than those that were

experienced by agricultural workers but were of a long-term

duration.5-10, 12, 14, 16-20, 25-27 Illnesses can result from both

high level, short-term exposures and lower level, long-term

exposures. The most common symptoms reported from exposures in

indoor environments are runny nose, eye irritation, cough,

congestion, aggravation of asthma, headache, and fatigue.11, 12, 16-

20

The presence of fungi on building materials as identified by a

visual assessment or by bulk/surface sampling results does not

necessitate that people will be exposed or exhibit health effects.

In order for humans to be exposed indoors, fungal spores, fragments,

or metabolites must be released into the air and inhaled, physically

contacted (dermal exposure), or ingested. Whether or not symptoms

develop in people exposed to fungi depends on the nature of the

fungal material (e.g., allergenic, toxic, or infectious), the amount

of exposure, and the susceptibility of exposed persons.

Susceptibility varies with the genetic predisposition (e.g.,

allergic reactions do not always occur in all individuals), age,

state of health, and concurrent exposures. For these reasons, and

because measurements of exposure are not standardized and biological

markers of exposure to fungi are largely unknown, it is not possible

to determine " safe " or " unsafe " levels of exposure for people in

general.

1.1.1 Immunological Effects

Immunological reactions include asthma, HP, and allergic rhinitis.

Contact with fungi may also lead to dermatitis. It is thought that

these conditions are caused by an immune response to fungal agents.

The most common symptoms associated with allergic reactions are

runny nose, eye irritation, cough, congestion, and aggravation of

asthma.11, 12 HP may occur after repeated exposures to an allergen

and can result in permanent lung damage. HP has typically been

associated with repeated heavy exposures in agricultural settings

but has also been reported in office settings.25, 26, 27 Exposure to

fungi through renovation work may also lead to initiation or

exacerbation of allergic or respiratory symptoms.

1.1.2 Toxic Effects

A wide variety of symptoms have been attributed to the toxic effects

of fungi. Symptoms, such as fatigue, nausea, and headaches, and

respiratory and eye irritation have been reported. Some of the

symptoms related to fungal exposure are non-specific, such as

discomfort, inability to concentrate, and fatigue.11, 12, 16-20

Severe illnesses such as ODTS and pulmonary hemosiderosis have also

been attributed to fungal exposures.5-10, 21, 22

ODTS describes the abrupt onset of fever, flu-like symptoms, and

respiratory symptoms in the hours following a single, heavy exposure

to dust containing organic material including fungi. It differs from

HP in that it is not an immune-mediated disease and does not require

repeated exposures to the same causative agent. ODTS may be caused

by a variety of biological agents including common species of fungi

(e.g., species of Aspergillus and Penicillium). ODTS has been

documented in farm workers handling contaminated material but is

also of concern to workers performing renovation work on building

materials contaminated with fungi.5-10

Some studies have suggested an association between SC and pulmonary

hemorrhage/hemosiderosis in infants, generally those less than six

months old. Pulmonary hemosiderosis is an uncommon condition that

results from bleeding in the lungs. The cause of this condition is

unknown, but may result from a combination of environmental

contaminants and conditions (e.g., smoking, fungal contaminants and

other bioaerosols, and water-damaged homes), and currently its

association with SC is unproven.21, 22, 23

1.1.3 Infectious Disease

Only a small group of fungi have been associated with infectious

disease. Aspergillosis is an infectious disease that can occur in

immunosuppressed persons. Health effects in this population can be

severe. Several species of Aspergillus are known to cause

aspergillosis. The most common is Aspergillus fumigatus. Exposure to

this common mold, even to high concentrations, is unlikely to cause

infection in a healthy person.11, 24

Exposure to fungi associated with bird and bat droppings (e.g.,

Histoplasma capsulatum and Cryptococcus neoformans) can lead to

health effects, usually transient flu-like illnesses, in healthy

individuals. Severe health effects are primarily encountered in

immunocompromised persons.24, 28, 29

1.2 Medical Evaluation

Individuals with persistent health problems that appear to be

related to fungi or other bioaerosol exposure should see their

physicians for a referral to practitioners who are trained in

occupational/environmental medicine or related specialties and are

knowledgeable about these types of exposures. Infants (less than 12

months old) who are experiencing non-traumatic nosebleeds or are

residing in dwellings with damp or moldy conditions and are

experiencing breathing difficulties should receive a medical

evaluation to screen for alveolar hemorrhage. Following this

evaluation, infants who are suspected of having alveolar

hemorrhaging should be referred to a pediatric pulmonologist.

Infants diagnosed with pulmonary hemosiderosis and/or pulmonary

hemorrhaging should not be returned to dwellings until remediation

and air testing are completed.

Clinical tests that can determine the source, place, or time of

exposure to fungi or their products are not currently available.

Antibodies developed by exposed persons to fungal agents can only

document that exposure has occurred. Since exposure to fungi

routinely occurs in both outdoor and indoor environments this

information is of limited value.

1.3 Medical Relocation

Infants (less than 12 months old), persons recovering from recent

surgery, or people with immune suppression, asthma, hypersensitivity

pneumonitis, severe allergies, sinusitis, or other chronic

inflammatory lung diseases may be at greater risk for developing

health problems associated with certain fungi. Such persons should

be removed from the affected area during remediation (see Section 3,

Remediation). Persons diagnosed with fungal related diseases should

not be returned to the affected areas until remediation and air

testing are completed.

Except in cases of widespread fungal contamination that are linked

to illnesses throughout a building, a building-wide evacuation is

not indicated. A trained occupational/environmental health

practitioner should base decisions about medical removals in the

occupational setting on the results of a clinical assessment.

2. Environmental Assessment The presence of mold, water damage, or

musty odors should be addressed immediately. In all instances, any

source(s) of water must be stopped and the extent of water damaged

determined. Water damaged materials should be dried and repaired.

Mold damaged materials should be remediated in accordance with this

document (see Section 3, Remediation).

2.1 Visual Inspection

A visual inspection is the most important initial step in

identifying a possible contamination problem. The extent of any

water damage and mold growth should be visually assessed. This

assessment is important in determining remedial strategies.

Ventilation systems should also be visually checked, particularly

for damp filters but also for damp conditions elsewhere in the

system and overall cleanliness. Ceiling tiles, gypsum wallboard

(sheetrock), cardboard, paper, and other cellulosic surfaces should

be given careful attention during a visual inspection. The use of

equipment such as a boroscope, to view spaces in ductwork or behind

walls, or a moisture meter, to detect moisture in building

materials, may be helpful in identifying hidden sources of fungal

growth and the extent of water damage.

2.2 Bulk/Surface Sampling

Bulk or surface sampling is not required to undertake a remediation.

Remediation (as described in Section 3, Remediation) of visually

identified fungal contamination should proceed without further

evaluation.

Bulk or surface samples may need to be collected to identify

specific fungal contaminants as part of a medical evaluation if

occupants are experiencing symptoms which may be related to fungal

exposure or to identify the presence or absence of mold if a visual

inspection is equivocal (e.g., discoloration, and staining).

An individual trained in appropriate sampling methodology should

perform bulk or surface sampling. Bulk samples are usually collected

from visibly moldy surfaces by scraping or cutting materials with a

clean tool into a clean plastic bag. Surface samples are usually

collected by wiping a measured area with a sterile swab or by

stripping the suspect surface with clear tape. Surface sampling is

less destructive than bulk sampling. Other sampling methods may also

be available. A laboratory specializing in mycology should be

consulted for specific sampling and delivery instructions.

2.3 Air Monitoring

Air sampling for fungi should not be part of a routine assessment.

This is because decisions about appropriate remediation strategies

can usually be made on the basis of a visual inspection. In

addition, air-sampling methods for some fungi are prone to false

negative results and therefore cannot be used to definitively rule

out contamination.

Air monitoring may be necessary if an individual(s) has been

diagnosed with a disease that is or may be associated with a fungal

exposure (e.g., pulmonary hemorrhage/hemosiderosis, and

aspergillosis).

Air monitoring may be necessary if there is evidence from a visual

inspection or bulk sampling that ventilation systems may be

contaminated. The purpose of such air monitoring is to assess the

extent of contamination throughout a building. It is preferable to

conduct sampling while ventilation systems are operating.

Air monitoring may be necessary if the presence of mold is suspected

(e.g., musty odors) but cannot be identified by a visual inspection

or bulk sampling (e.g., mold growth behind walls). The purpose of

such air monitoring is to determine the location and/or extent of

contamination.

If air monitoring is performed, for comparative purposes, outdoor

air samples should be collected concurrently at an air intake, if

possible, and at a location representative of outdoor air. For

additional information on air sampling, refer to the American

Conference of Governmental Industrial Hygienists'

document, " Bioaerosols: Assessment and Control. "

Personnel conducting the sampling must be trained in proper air

sampling methods for microbial contaminants. A laboratory

specializing in mycology should be consulted for specific sampling

and shipping instructions.

2.4 Analysis of Environmental Samples

Microscopic identification of the spores/colonies requires

considerable expertise. These services are not routinely available

from commercial laboratories. Documented quality control in the

laboratories used for analysis of the bulk/surface and air samples

is necessary. The American Industrial Hygiene Association (AIHA)

offers accreditation to microbial laboratories (Environmental

Microbiology Laboratory Accreditation Program (EMLAP)). Accredited

laboratories must participate in quarterly proficiency testing

(Environmental Microbiology Proficiency Analytical Testing Program

(EMPAT)).

Evaluation of bulk/surface and air sampling data should be performed

by an experienced health professional. The presence of few or trace

amounts of fungal spores in bulk/surface sampling should be

considered background. Amounts greater than this or the presence of

fungal fragments (e.g., hyphae, and conidiophores) may suggest

fungal colonization, growth, and/or accumulation at or near the

sampled location.30 Air samples should be evaluated by means of

comparison (i.e., indoors to outdoors) and by fungal type (e.g.,

genera, and species). In general, the levels and types of fungi

found should be similar indoors (in non-problem buildings) as

compared to the outdoor air. Differences in the levels or types of

fungi found in air samples may indicate that moisture sources and

resultant fungal growth may be problematic.

3. Remediation In all situations, the underlying cause of water

accumulation must be rectified or fungal growth will recur. Any

initial water infiltration should be stopped and cleaned

immediately. An immediate response (within 24 to 48 hours) and

thorough clean up, drying, and/or removal of water damaged materials

will prevent or limit mold growth. If the source of water is

elevated humidity, relative humidity should be maintained at levels

below 60% to inhibit mold growth.31 Emphasis should be on ensuring

proper repairs of the building infrastructure, so that water damage

and moisture buildup does not recur.

Five different levels of abatement are described below. The size of

the area impacted by fungal contamination primarily determines the

type of remediation. The sizing levels below are based on

professional judgement and practicality; currently there is not

adequate data to relate the extent of contamination to frequency or

severity of health effects. The goal of remediation is to remove or

clean contaminated materials in a way that prevents the emission of

fungi and dust contaminated with fungi from leaving a work area and

entering an occupied or non-abatement area, while protecting the

health of workers performing the abatement. The listed remediation

methods were designed to achieve this goal, however, due to the

general nature of these methods it is the responsibility of the

people conducting remediation to ensure the methods enacted are

adequate. The listed remediation methods are not meant to exclude

other similarly effective methods. Any changes to the remediation

methods listed in these guidelines, however, should be carefully

considered prior to implementation.

Non-porous (e.g., metals, glass, and hard plastics) and semi-porous

(e.g., wood, and concrete) materials that are structurally sound and

are visibly moldy can be cleaned and reused. Cleaning should be done

using a detergent solution. Porous materials such as ceiling tiles

and insulation, and wallboards with more than a small area of

contamination should be removed and discarded. Porous materials

(e.g., wallboard, and fabrics) that can be cleaned, can be reused,

but should be discarded if possible. A professional restoration

consultant should be contacted when restoring porous materials with

more than a small area of fungal contamination. All materials to be

reused should be dry and visibly free from mold. Routine inspections

should be conducted to confirm the effectiveness of remediation

work.

The use of gaseous, vapor-phase, or aerosolized biocides for

remedial purposes is not recommended. The use of biocides in this

manner can pose health concerns for people in occupied spaces of the

building and for people returning to the treated space if used

improperly. Furthermore, the effectiveness of these treatments is

unproven and does not address the possible health concerns from the

presence of the remaining non-viable mold. For additional

information on the use of biocides for remedial purposes, refer to

the American Conference of Governmental Industrial Hygienists'

document, " Bioaerosols: Assessment and Control. "

3.1 Level I: Small Isolated Areas (10 sq. ft or less) - e.g.,

ceiling tiles, small areas on walls

Remediation can be conducted by regular building maintenance staff.

Such persons should receive training on proper clean up methods,

personal protection, and potential health hazards. This training can

be performed as part of a program to comply with the requirements of

the OSHA Hazard Communication Standard (29 CFR 1910.1200).

Respiratory protection (e.g., N95 disposable respirator), in

accordance with the OSHA respiratory protection standard (29 CFR

1910.134), is recommended. Gloves and eye protection should be worn.

The work area should be unoccupied. Vacating people from spaces

adjacent to the work area is not necessary but is recommended in the

presence of infants (less than 12 months old), persons recovering

from recent surgery, immune suppressed people, or people with

chronic inflammatory lung diseases (e.g., asthma, hypersensitivity

pneumonitis, and severe allergies).

Containment of the work area is not necessary. Dust suppression

methods, such as misting (not soaking) surfaces prior to

remediation, are recommended.

Contaminated materials that cannot be cleaned should be removed from

the building in a sealed plastic bag. There are no special

requirements for the disposal of moldy materials.

The work area and areas used by remedial workers for egress should

be cleaned with a damp cloth and/or mop and a detergent solution.

All areas should be left dry and visibly free from contamination and

debris.

3.2 Level II: Mid-Sized Isolated Areas (10 - 30 sq. ft.) - e.g.,

individual wallboard panels.

Remediation can be conducted by regular building maintenance staff.

Such persons should receive training on proper clean up methods,

personal protection, and potential health hazards. This training can

be performed as part of a program to comply with the requirements of

the OSHA Hazard Communication Standard (29 CFR 1910.1200).

Respiratory protection (e.g., N95 disposable respirator), in

accordance with the OSHA respiratory protection standard (29 CFR

1910.134), is recommended. Gloves and eye protection should be worn.

The work area should be unoccupied. Vacating people from spaces

adjacent to the work area is not necessary but is recommended in the

presence of infants (less than 12 months old), persons having

undergone recent surgery, immune suppressed people, or people with

chronic inflammatory lung diseases (e.g., asthma, hypersensitivity

pneumonitis, and severe allergies).

The work area should be covered with a plastic sheet(s) and sealed

with tape before remediation, to contain dust/debris.

Dust suppression methods, such as misting (not soaking) surfaces

prior to remediation, are recommended.

Contaminated materials that cannot be cleaned should be removed from

the building in sealed plastic bags. There are no special

requirements for the disposal of moldy materials.

The work area and areas used by remedial workers for egress should

be HEPA vacuumed (a vacuum equipped with a High-Efficiency

Particulate Air filter) and cleaned with a damp cloth and/or mop and

a detergent solution.

All areas should be left dry and visibly free from contamination and

debris.

3.3 Level III: Large Isolated Areas (30 - 100 square feet) - e.g.,

several wallboard panels.

A health and safety professional with experience performing

microbial investigations should be consulted prior to remediation

activities to provide oversight for the project.

The following procedures at a minimum are recommended:

Personnel trained in the handling of hazardous materials and

equipped with respiratory protection, (e.g., N95 disposable

respirator), in accordance with the OSHA respiratory protection

standard (29 CFR 1910.134), is recommended. Gloves and eye

protection should be worn.

The work area and areas directly adjacent should be covered with a

plastic sheet(s) and taped before remediation, to contain

dust/debris.

Seal ventilation ducts/grills in the work area and areas directly

adjacent with plastic sheeting.

The work area and areas directly adjacent should be unoccupied.

Further vacating of people from spaces near the work area is

recommended in the presence of infants (less than 12 months old),

persons having undergone recent surgery, immune suppressed people,

or people with chronic inflammatory lung diseases (e.g., asthma,

hypersensitivity pneumonitis, and severe allergies).

Dust suppression methods, such as misting (not soaking) surfaces

prior to remediation, are recommended.

Contaminated materials that cannot be cleaned should be removed from

the building in sealed plastic bags. There are no special

requirements for the disposal of moldy materials.

The work area and surrounding areas should be HEPA vacuumed and

cleaned with a damp cloth and/or mop and a detergent solution.

All areas should be left dry and visibly free from contamination and

debris.

If abatement procedures are expected to generate a lot of dust

(e.g., abrasive cleaning of contaminated surfaces, demolition of

plaster walls) or the visible concentration of the fungi is heavy

(blanket coverage as opposed to patchy), then it is recommended that

the remediation procedures for Level IV are followed.

3.4 Level IV: Extensive Contamination (greater than 100 contiguous

square feet in an area)

A health and safety professional with experience performing

microbial investigations should be consulted prior to remediation

activities to provide oversight for the project. The following

procedures are recommended:

Personnel trained in the handling of hazardous materials equipped

with:

Full-face respirators with high efficiency particulate air (HEPA)

cartridges

Disposable protective clothing covering both head and shoes

Gloves

Containment of the affected area:

Complete isolation of work area from occupied spaces using plastic

sheeting sealed with duct tape (including ventilation ducts/grills,

fixtures, and any other openings)

The use of an exhaust fan with a HEPA filter to generate negative

pressurization

Airlocks and decontamination room

Vacating people from spaces adjacent to the work area is not

necessary but is recommended in the presence of infants (less than

12 months old), persons having undergone recent surgery, immune

suppressed people, or people with chronic inflammatory lung diseases

(e.g., asthma, hypersensitivity pneumonitis, and severe allergies).

Contaminated materials that cannot be cleaned should be removed from

the building in sealed plastic bags. The outside of the bags should

be cleaned with a damp cloth and a detergent solution or HEPA

vacuumed in the decontamination chamber prior to their transport to

uncontaminated areas of the building. There are no special

requirements for the disposal of moldy materials.

The contained area and decontamination room should be HEPA vacuumed

and cleaned with a damp cloth and/or mop with a detergent solution

and be visibly clean prior to the removal of isolation barriers.

Air monitoring should be conducted prior to occupancy to determine

if the area is fit to reoccupy.

3.5 Level V: Remediation of HVAC Systems

3.5.1 A Small Isolated Area of Contamination (<10 square feet) in

the HVAC System

Remediation can be conducted by regular building maintenance staff.

Such persons should receive training on proper clean up methods,

personal protection, and potential health hazards. This training can

be performed as part of a program to comply with the requirements of

the OSHA Hazard Communication Standard (29 CFR 1910.1200).

Respiratory protection (e.g., N95 disposable respirator), in

accordance with the OSHA respiratory protection standard (29 CFR

1910.134), is recommended. Gloves and eye protection should be worn.

The HVAC system should be shut down prior to any remedial

activities.

The work area should be covered with a plastic sheet(s) and sealed

with tape before remediation, to contain dust/debris.

Dust suppression methods, such as misting (not soaking) surfaces

prior to remediation, are recommended.

Growth supporting materials that are contaminated, such as the paper

on the insulation of interior lined ducts and filters, should be

removed. Other contaminated materials that cannot be cleaned should

be removed in sealed plastic bags. There are no special requirements

for the disposal of moldy materials.

The work area and areas immediately surrounding the work area should

be HEPA vacuumed and cleaned with a damp cloth and/or mop and a

detergent solution.

All areas should be left dry and visibly free from contamination and

debris.

A variety of biocides are recommended by HVAC manufacturers for use

with HVAC components, such as, cooling coils and condensation pans.

HVAC manufacturers should be consulted for the products they

recommend for use in their systems.

3.5.2 Areas of Contamination (>10 square feet) in the HVAC System

A health and safety professional with experience performing

microbial investigations should be consulted prior to remediation

activities to provide oversight for remediation projects involving

more than a small isolated area in an HVAC system. The following

procedures are recommended:

Personnel trained in the handling of hazardous materials equipped

with:

Respiratory protection (e.g., N95 disposable respirator), in

accordance with the OSHA respiratory protection standard (29 CFR

1910.134), is recommended.

Gloves and eye protection

Full-face respirators with HEPA cartridges and disposable protective

clothing covering both head and shoes should be worn if

contamination is greater than 30 square feet.

The HVAC system should be shut down prior to any remedial

activities.

Containment of the affected area:

Complete isolation of work area from the other areas of the HVAC

system using plastic sheeting sealed with duct tape.

The use of an exhaust fan with a HEPA filter to generate negative

pressurization.

Airlocks and decontamination room if contamination is greater than

30 square feet.

Growth supporting materials that are contaminated, such as the paper

on the insulation of interior lined ducts and filters, should be

removed. Other contaminated materials that cannot be cleaned should

be removed in sealed plastic bags. When a decontamination chamber is

present, the outside of the bags should be cleaned with a damp cloth

and a detergent solution or HEPA vacuumed prior to their transport

to uncontaminated areas of the building. There are no special

requirements for the disposal of moldy materials.

The contained area and decontamination room should be HEPA vacuumed

and cleaned with a damp cloth and/or mop and a detergent solution

prior to the removal of isolation barriers.

All areas should be left dry and visibly free from contamination and

debris.

Air monitoring should be conducted prior to re-occupancy with the

HVAC system in operation to determine if the area(s) served by the

system are fit to reoccupy.

A variety of biocides are recommended by HVAC manufacturers for use

with HVAC components, such as, cooling coils and condensation pans.

HVAC manufacturers should be consulted for the products they

recommend for use in their systems.

4. Hazard Communication When fungal growth requiring large-scale

remediation is found, the building owner, management, and/or

employer should notify occupants in the affected area(s) of its

presence. Notification should include a description of the remedial

measures to be taken and a timetable for completion. Group meetings

held before and after remediation with full disclosure of plans and

results can be an effective communication mechanism. Individuals

with persistent health problems that appear to be related to

bioaerosol exposure should see their physicians for a referral to

practitioners who are trained in occupational/environmental medicine

or related specialties and are knowledgeable about these types of

exposures. Individuals seeking medical attention should be provided

with a copy of all inspection results and interpretation to give to

their medical practitioners.

Conclusion In summary, the prompt remediation of contaminated

material and infrastructure repair must be the primary response to

fungal contamination in buildings. The simplest and most expedient

remediation that properly and safely removes fungal growth from

buildings should be used. In all situations, the underlying cause of

water accumulation must be rectified or the fungal growth will

recur. Emphasis should be placed on preventing contamination through

proper building maintenance and prompt repair of water damaged

areas.

Widespread contamination poses much larger problems that must be

addressed on a case-by-case basis in consultation with a health and

safety specialist. Effective communication with building occupants

is an essential component of all remedial efforts. Individuals with

persistent health problems should see their physicians for a

referral to practitioners who are trained in

occupational/environmental medicine or related specialties and are

knowledgeable about these types of exposures.

Notes and References

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Trichothecene Toxins Produced by Stachybotrys atra Strains Isolated

in Middle Europe. Applied and Environmental Microbiology 1985;

49:678-81.

Jarvis B, " Mycotoxins and Indoor Air Quality, " Biological

Contaminants in Indoor Environments, ASTM STP 1071, Morey P, Feely

Sr. J, Otten J, Editors, American Society for Testing and Materials,

Philadelphia, 1990.

Yang C, Johanning E, " Airborne Fungi and Mycotoxins, " Manual of

Environmental Microbiology, Hurst C, Editor in Chief, ASM Press,

Washington, D.C., 1996

Jarvis B, Mazzola E. Macrocyclic and Other Novel Trichothecenes:

Their Structure, Synthesis, and Biological Significance. Acc. Chem.

Res. 1982; 15:388-95.

Von Essen S, Robbins R, A, Rennard S. Organic Dust Toxic

Syndrome: An Acute Febrile Reaction to Organic Dust Exposure

Distinct from Hypersensitivity Pneumonitis. Clinical Toxicology

1990; 28(4):389-420.

Richerson H. Unifying Concepts Underlying the Effects of Organic

Dust Exposures. American Journal of Industrial Medicine 1990; 17:139-

42.

Malmberg P, Rask-Andersen A, Lundholm M, Palmgren U. Can Spores from

Molds and Actinomycetes Cause an Organic Dust Toxic Syndrome

Reaction?. American Journal of Industrial Medicine 1990; 17:109-10.

Malmberg P. Health Effects of Organic Dust Exposure in Dairy

Farmers. American Journal of Industrial Medicine 1990; 17:7-15.

Yoshida K, Masayuki A, Shukuro A. Acute Pulmonary Edema in a

Storehouse of Moldy Oranges: A Severe Case of the Organic Dust Toxic

Syndrome. Archives of Environmental Health 1989; 44(6): 382-84.

Lecours R, Laviolette M, Cormier Y. Bronchoalveolar Lavage in

Pulmonary Mycotoxicosis. Thorax 1986; 41:924-6.

Levetin E. " Fungi, " Bioaerosols, Burge H, Editor, CRC Press, Boca

Raton, Florida, 1995.

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Environ Health 1996; 22:5-13.

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Product Research. J Stored Prod Res 1995; 31(1):1-16.

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Diseases, " Bioaerosols, Burge H, Editor, CRC Press, Boca Raton,

Florida, 1995.

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Control of Exposure to Airborne Viable Microorganisms During

Remediation of Moldy Buildings; Report of Three Case Studies.

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Effects of Home Dampness and Molds among Canadian Children. American

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Exposure to Stachybotrys chartarum and Aspergillus versicolor.

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Toxicosis. Atmospheric Environment 1986; 20(3)549-52.

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Health and Immunological Study Following Exposure to Toxigenic Fungi

(Stachybotrys chartarum) in a Water-Damaged Office Environment. Int

Arch Occup Environ Health 1996; 68:207-18.

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Risk Factor Associated with Pediatric Idiopathic Pulmonary

Hemorrhage and Hemosiderosis in a Cleveland Community. Pediatrics

1997; 99(1)

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Acute Pulmonary Hemorrhage in Infants Associated with Exposure to

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152:757-62.

CDC. Update: Pulmonary Hemorrhage/Hemosiderosis Among Infants ---

Cleveland, Ohio, 1993 - 1996. MMWR 2000; 49(9): 180-4.

Burge H, Otten J. " Fungi, " Bioaerosols Assessment and Control,

Macher J, Editor, American Conference of Industrial Hygienists,

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do Pico G. Hazardous Exposure and Lung Disease Among Farm Workers.

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Acknowledgments The New York City Department of Health would like to

thank the following individuals and organizations for participating

in the revision of these guidelines. Please note that these

guidelines do not necessarily reflect the opinions of the

participants nor their organizations.

Name

Company/Institution

Dr. Klitzman

Hunter College

Dr. Philip Morey

AQS Services, Inc

Dr. Ahearn

Georgia State University

Dr. Sidney Crow

Georgia State University

Dr. J.

Carleton University

Dr. Bruce Jarvis

University of land at College Park

Mr. Ed Light

Building Dynamics, LLC

Dr. Chin Yang

P & K Microbiology Services, Inc

Dr. Harriet Burge

Harvard School of Public Health

Dr. Dorr Dearborn

Rainbow Children's Hospital

Mr. Esswein

National Institute for Occupational Safety and Health

Dr. Ed Horn

The New York State Department of Health

Dr. Judith Schreiber

The New York State Department of Health

Mr. Gregg Recer

The New York State Department of Health

Dr. Gerald Llewellyn

State of Delaware, Division of Public Health

Mr. Price

Interface Research Corporation

Ms. Sylvia Pryce

The NYC Citywide Office of Occupational Safety and Health

Mr. Chamorro

Ambient Environmental

Ms. Marie-Alix d'Halewyn

Laboratoire de santé publique du Québec

Dr. Elissa A. Favata

Environmental and Occupational Health Associates

Dr. Harriet Ammann

Washington State Department of Health

Mr. Terry Allan

Cuyahoga County Board of Health

We would also like to thank the many others who offered opinions,

comments, and assistance at various stages during the development of

these guidelines.

D', M.S. of the Environmental and Occupational

Disease Epidemiology Unit, was the editor of this document.

For further information regarding this document please contact the

New York City Department of Health at 311.

http://www.nyc.gov/html/doh/html/epi/moldrpt1.shtml

# # #

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