Indoor Mold
Better Coordination of Research on Health Effects and More Consistent Guidance Would Improve Federal Efforts
Gao ID: GAO-08-980 September 30, 2008
Recent research suggests that indoor mold poses a widespread and, for some people, serious health threat. Federal agencies engage in a number of activities to address this issue, including conducting or sponsoring research. For example, in 2004 the National Academies' Institute of Medicine issued a report requested by the Department of Health and Human Services (HHS) summarizing the scientific literature on mold, dampness, and human health. In addition, the Federal Interagency Committee on Indoor Air Quality supports the Environmental Protection Agency's (EPA) indoor air research program. With respect to the health effects of exposure to indoor mold, GAO was asked to report on (1) the conclusions of recent reviews of the scientific literature, (2) the extent to which federal research addresses data gaps, and (3) the guidance agencies are providing to the general public. GAO reviewed scientific literature on indoor mold's health effects, surveyed three agencies that conduct or sponsor indoor mold research, and analyzed guidance issued by five agencies.
In general, the Institute of Medicine's 2004 report, and reviews of the scientific literature published from 2005 to 2007 that GAO examined, concluded that certain adverse health effects are more clearly associated with exposure to indoor mold than others. For example, the Institute of Medicine concluded that some respiratory effects, such as exacerbation of pre-existing asthma, are associated with exposure to indoor mold but that the available evidence was not sufficient to determine whether mold and a variety of other health effects, such as the development of asthma, cancer, and acute pulmonary hemorrhage in infants, are associated. While the reviews GAO examined generally agreed with these conclusions, a few judged the evidence for some health effects as somewhat stronger. For example, the American Academy of Pediatrics concluded in 2006 that a plausible link exists between acute pulmonary hemorrhage in infants and exposure to toxins that some molds produce. In addition, the 2004 Institute of Medicine report identified the need for additional research to address a number of data gaps related to the health effects of indoor mold. The 65 ongoing federal research activities on the health effects of exposure to indoor mold conducted or sponsored by EPA, HHS, and the Department of Housing and Urban Development (HUD) address to varying extents 15 gaps in scientific data reported by the Institute of Medicine. For example, many of the research activities address data gaps related to asthma and measurement methods, while other data gaps, such as those related to toxins produced by some molds, are being minimally addressed. Further, less than half of the ongoing mold-related research activities are coordinated either within or across agencies. This limited coordination is important in light of, among other things, the wide range of data gaps identified by the Institute of Medicine and limited federal resources. The Federal Interagency Committee on Indoor Air Quality could provide a structured mechanism for coordinating research activities on mold and other indoor air issues by, for example, serving as a forum for reviewing and prioritizing agencies' ongoing and planned research. However, it currently does not do so. Despite limitations of scientific evidence regarding a number of potential health effects of exposure to indoor mold, enough is known that federal agencies have issued guidance to the general public about health risks associated with exposure to indoor mold and how to minimize mold growth and mitigate exposure. For example, guidance issued by the Consumer Product Safety Commission, EPA, the Federal Emergency Management Agency, HHS, and HUD cites a variety of health effects of exposure to indoor mold but in some cases omits less common but serious effects. Moreover, while guidance on minimizing indoor mold growth is generally consistent, guidance on mitigating exposure to indoor mold is sometimes inconsistent about cleanup agents, protective clothing and equipment, and sensitive populations. As a result, the public may not be sufficiently advised of indoor mold's potential health risks.
Recommendations
Our recommendations from this work are listed below with a Contact for more information. Status will change from "In process" to "Open," "Closed - implemented," or "Closed - not implemented" based on our follow up work.
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GAO-08-980, Indoor Mold: Better Coordination of Research on Health Effects and More Consistent Guidance Would Improve Federal Efforts
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Report to the Chairman, Committee on Health, Education, Labor and
Pensions, U.S. Senate:
United States Government Accountability Office:
GAO:
September 2008:
Indoor Mold:
Better Coordination of Research on Health Effects and More Consistent
Guidance Would Improve Federal Efforts:
GAO-08-980:
GAO Highlights:
Highlights of GAO-08-980, a report to the Chairman, Committee on
Health, Education, Labor and Pensions, U.S. Senate.
Why GAO Did This Study:
Recent research suggests that indoor mold poses a widespread and, for
some people, serious health threat. Federal agencies engage in a number
of activities to address this issue, including conducting or sponsoring
research. For example, in 2004 the National Academies‘ Institute of
Medicine issued a report requested by the Department of Health and
Human Services (HHS) summarizing the scientific literature on mold,
dampness, and human health. In addition, the Federal Interagency
Committee on Indoor Air Quality supports the Environmental Protection
Agency‘s (EPA) indoor air research program. With respect to the health
effects of exposure to indoor mold, GAO was asked to report on (1) the
conclusions of recent reviews of the scientific literature, (2) the
extent to which federal research addresses data gaps, and (3) the
guidance agencies are providing to the general public. GAO reviewed
scientific literature on indoor mold‘s health effects, surveyed three
agencies that conduct or sponsor indoor mold research, and analyzed
guidance issued by five agencies.
What GAO Found:
In general, the Institute of Medicine‘s 2004 report, and reviews of the
scientific literature published from 2005 to 2007 that GAO examined,
concluded that certain adverse health effects are more clearly
associated with exposure to indoor mold than others. For example, the
Institute of Medicine concluded that some respiratory effects, such as
exacerbation of pre-existing asthma, are associated with exposure to
indoor mold but that the available evidence was not sufficient to
determine whether mold and a variety of other health effects, such as
the development of asthma, cancer, and acute pulmonary hemorrhage in
infants, are associated. While the reviews GAO examined generally
agreed with these conclusions, a few judged the evidence for some
health effects as somewhat stronger. For example, the American Academy
of Pediatrics concluded in 2006 that a plausible link exists between
acute pulmonary hemorrhage in infants and exposure to toxins that some
molds produce. In addition, the 2004 Institute of Medicine report
identified the need for additional research to address a number of data
gaps related to the health effects of indoor mold.
The 65 ongoing federal research activities on the health effects of
exposure to indoor mold conducted or sponsored by EPA, HHS, and the
Department of Housing and Urban Development (HUD) address to varying
extents 15 gaps in scientific data reported by the Institute of
Medicine. For example, many of the research activities address data
gaps related to asthma and measurement methods, while other data gaps,
such as those related to toxins produced by some molds, are being
minimally addressed. Further, less than half of the ongoing mold-
related research activities are coordinated either within or across
agencies. This limited coordination is important in light of, among
other things, the wide range of data gaps identified by the Institute
of Medicine and limited federal resources. The Federal Interagency
Committee on Indoor Air Quality could provide a structured mechanism
for coordinating research activities on mold and other indoor air
issues by, for example, serving as a forum for reviewing and
prioritizing agencies‘ ongoing and planned research. However, it
currently does not do so.
Despite limitations of scientific evidence regarding a number of
potential health effects of exposure to indoor mold, enough is known
that federal agencies have issued guidance to the general public about
health risks associated with exposure to indoor mold and how to
minimize mold growth and mitigate exposure. For example, guidance
issued by the Consumer Product Safety Commission, EPA, the Federal
Emergency Management Agency, HHS, and HUD cites a variety of health
effects of exposure to indoor mold but in some cases omits less common
but serious effects. Moreover, while guidance on minimizing indoor mold
growth is generally consistent, guidance on mitigating exposure to
indoor mold is sometimes inconsistent about cleanup agents, protective
clothing and equipment, and sensitive populations. As a result, the
public may not be sufficiently advised of indoor mold‘s potential
health risks.
What GAO Recommends:
GAO recommends that EPA use the interagency committee on indoor air to
(1) help guide federal research priorities on indoor mold and (2) help
agencies better ensure that their guidance to the public does not
conflict, among other things. In commenting on a draft of our report,
EPA agreed with our recommendations.
To view the full product, including the scope and methodology, click on
[hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-980]. To view the
survey results, click on GAO-08-984SP. For more information, contact
John B. Stephenson at (202) 512-3841 or stephensonj@gao.gov.
[End of section]
Contents:
Letter:
Results in Brief:
Background:
Many Studies Associate Indoor Mold with Adverse Health Effects but Cite
the Need for Additional Research:
Federal Research Activities on the Health Effects of Indoor Mold
Address Data Gaps to Varying Degrees; Limited Planning and Coordination
of the Activities May Reduce Their Ability to Close Data Gaps:
Federal Guidance to the General Public Identifies Various Health
Effects Associated with Exposure to Indoor Mold, as well as Strategies
to Limit It, Some of Which Are Inconsistent:
Conclusions:
Recommendations for Executive Action:
Agency Comments and Our Evaluation:
Appendix I: Objectives, Scope, and Methodology:
Appendix II: Recent Reviews of the Health Effects of Mold:
Appendix III: EPA, HHS, and HUD Ongoing Research Activities Addressing
Data Gaps Identified by the Institute of Medicine:
Appendix IV: Federal Agency Program Offices Contacted Regarding Their
Mold-Related Research:
Appendix V: Selected Publicly Available Federal Guidance Related to
Mold:
Appendix VI: GAO Contact and Staff Acknowledgments:
Table:
Table 1: Potential Adverse Health Effects of Exposure to Indoor Mold
Cited in Six or More Guidance Documents, by Federal Agency:
Figures:
Figure 1: Coordination of Ongoing Federal Mold Research Activities
within the Agency or among Other Federal Agencies, as of October 1,
2007:
Figure 2: Varying Levels of Personal Protection for Cleaning Limited
Mold Contamination, as Recommended by Selected Federal Guidance:
Abbreviations:
CDC: Centers for Disease Control and Prevention:
DOE: Department of Energy:
EPA: Environmental Protection Agency:
ERMI: Environmental Relative Moldiness Index:
FEMA: Federal Emergency Management Agency:
HHS: Department of Health and Human Services:
HUD: Department of Housing and Urban Development:
NIH: National Institutes of Health:
NIOSH: National Institute for Occupational Safety and Health:
OSHA: Occupational Safety and Health Administration:
[End of section]
United States Government Accountability Office:
Washington, DC 20548:
September 30, 2008:
The Honorable Edward M. Kennedy:
Chairman:
Committee on Health, Education, Labor and Pensions:
United States Senate:
Dear Mr. Chairman:
Mold is a general term for certain microorganisms that thrive in damp
conditions and are regularly found in indoor air and on materials and
surfaces, such as walls.[Footnote 1] While indoor mold was considered
largely a nuisance as recently as 25 years ago, scientific and medical
research is now suggesting that mold poses a widespread and, for some
people, serious health threat.[Footnote 2] The presence of moisture is
the primary factor leading to mold growth indoors. In the wake of
Hurricanes Katrina and Rita in 2005 and the extensive flooding of homes
that followed, the Department of Health and Human Services' (HHS)
Centers for Disease Control and Prevention (CDC) concluded that
"excessive exposure to mold-contaminated materials can cause adverse
health effects in susceptible persons regardless of the type of mold or
the extent of contamination."[Footnote 3] A variety of health effects
have been directly linked to exposure to indoor mold, although the
connection to many of the more severe effects, such as acute lung
hemorrhaging in infants, remains inconclusive.
Several components and products of mold may cause disease. Mold grows
as a mass of microscopic filaments, fragments of which may cause
adverse health effects. In addition, the spores that mold releases to
reproduce, along with certain components of mold's cell walls, may also
cause adverse health effects. Mold products--for example, allergens,
volatile gases that often create a musty odor, and toxins released by
certain types of mold under certain conditions--can also cause disease.
An example of a toxin-producing mold is Stachybotrys chartarum, which
produces multiple toxins that may suppress the functioning of immune
cells.
Mold may affect human health through a number of routes and mechanisms.
While inhalation is generally the most common route of exposure for
mold in indoor environments, exposure can also occur through ingestion
(for example, hand-to-mouth contact) and contact with the skin. The
roles of these routes of exposure in causing illness are unclear. Once
exposure occurs, health effects may arise through several potential
mechanisms, including allergic (or immune-mediated), infectious, and
toxic. It is not always possible to determine which of these mechanisms
is associated with a specific health outcome.
Although federal agencies are engaged in a number of efforts to address
indoor mold, there are no federal or generally accepted health-based
standards for safe levels of mold in the air or on surfaces. According
to EPA officials, the lack of federal regulation of airborne
concentrations of mold indoors is largely due to the insufficiency of
data needed to establish a scientifically defensible health-based
standard. Another factor is the lack of scientific consensus regarding
how best to measure these concentrations. The presence of mold in homes
and workplaces has led to numerous lawsuits. For example, highly
publicized cases involving mold include a Texas homeowner's successful
multi-million-dollar lawsuit against an insurance company related to
mold contamination. Moreover, mold contamination at the Walter Reed
Army Medical Center, where soldiers returning from Iraq are being
treated, received significant media coverage.
In 2001, recognizing the need for credible and comprehensive
information on the health effects of exposure to indoor mold, HHS
commissioned the National Academies' Institute of Medicine to review
the available scientific literature on the links among mold, dampness,
and human health.[Footnote 4] In 2004, the Institute of Medicine issued
its report, which made a variety of recommendations for research aimed
at better understanding the health risks of exposure to indoor mold.
[Footnote 5] Currently, a number of federal agencies conduct mold-
related research or provide guidance to the public on health effects
associated with exposure to mold and on ways to mitigate such exposure.
These federal agencies include the Environmental Protection Agency
(EPA); the Department of Housing and Urban Development (HUD); the
Consumer Product Safety Commission; the Federal Emergency Management
Agency (FEMA); and HHS and a number of its entities, such as CDC and
the National Institutes of Health (NIH). In 1983, a congressional
committee directed the establishment of the Federal Interagency
Committee on Indoor Air Quality to coordinate federal indoor air
quality research. The research on indoor mold is a small component of
indoor air research activities, and it is conducted or sponsored by a
number of different entities within and across agencies. EPA serves
both as the executive secretary of the interagency committee and as a
co-chair; other federal departments and agencies participate as co-
chairs and members.
You asked us to determine (1) what recent reviews of scientific
literature have concluded about the health effects of exposure to
indoor mold; (2) the extent to which federal research addresses data
gaps related to the health effects of exposure to indoor mold; and (3)
the guidance key federal agencies are providing to the general public
on the health risks of exposure to mold, minimizing mold growth, and
mitigating exposure to mold, and the extent to which the guidance is
consistent. For the first objective, we analyzed the 2000 and 2004
Institute of Medicine reports, Clearing the Air: Asthma and Indoor Air
Exposures and Damp Indoor Spaces and Health.[Footnote 6] We also
analyzed 20 reviews of the scientific literature on the health effects
of exposure to indoor mold that were published from 2005 to 2007; we
did not review individual studies. To obtain information on federal
research related to the health effects of exposure to indoor mold, we
conducted two surveys of officials at EPA, HHS, and HUD from November
2007 to May 2008. We focused on these agencies because of their past
and current research activities on the health effects of mold. We used
one survey to (1) identify research activities related to the health
effects of indoor mold ongoing as of October 1, 2007, and (2) determine
the extent to which these research activities address the 15 data gaps
identified in the 2000 and 2004 Institute of Medicine reports related
to the health effects of exposure to indoor mold. We also used this
survey to identify the extent to which these activities were
coordinated both within and across agencies. We conducted a second
survey of these agencies to collect basic information regarding their
mold-related research activities completed from January 1, 2005, to
September 30, 2007. Overall, we received information on 107 research
activities from 37 EPA, HHS, and HUD officials. Summaries of the
research activities conducted or sponsored by EPA, HHS, and HUD are
provided in a supplement to this report (see [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-08-984SP]). We also examined the
extent to which the Federal Interagency Committee on Indoor Air Quality
has been used to coordinate federal research activities related to the
health effects of exposure to indoor mold. To evaluate guidance
documents issued to the public by federal agencies, we focused on the
five federal agencies primarily responsible for providing information
to the general public on health risks and minimizing and mitigating
exposure to contaminants, including mold--the Consumer Product Safety
Commission, EPA, FEMA, HHS, and HUD. Our review focuses on the health
effects and guidance to the general public related to indoor mold in
homes and does not address occupational exposures or technical guidance
documents targeted to specialized audiences such as medical
professionals. Appendix I provides a more detailed description of our
scope and methodology. We conducted this performance audit from January
2007 to September 2008 in accordance with generally accepted government
auditing standards. Those standards require that we plan and perform
the audit to obtain sufficient, appropriate evidence to provide a
reasonable basis for our findings and conclusions based on our audit
objectives. We believe that the evidence obtained provides a reasonable
basis for our findings and conclusions based on our audit objectives.
Results in Brief:
In general, the Institute of Medicine's 2004 comprehensive report, as
well as reviews of the scientific literature published from 2005 to
2007 that we examined, concluded that certain adverse health effects
are more clearly associated with exposure to indoor mold than others.
For example, the Institute of Medicine's report said that certain
respiratory effects, such as nasal congestion and the exacerbation of
pre-existing asthma, are associated with exposure to indoor mold but
that the available evidence was not sufficient to determine whether
associations exist between mold and a variety of other health effects,
such as the development of asthma, rheumatologic and other immune
diseases, cancer, acute pulmonary hemorrhage in infants, and
reproductive effects. While the more recent scientific reviews we
examined generally concurred with these conclusions, a few of the
reviews judged the available evidence for some of these health effects
to be somewhat stronger. For example, the American Academy of
Pediatrics concluded in 2006 that a plausible link exists between acute
pulmonary hemorrhage in infants and exposure to certain toxins that
some molds produce. Conclusively associating exposure to mold with
certain health effects is challenging, according to the Institute of
Medicine's 2004 report, because available studies have been of
insufficient quality, consistency, or rigor. Two key research issues
contribute to this difficulty: (1) the lack of standardized,
quantitative methods of measuring exposure to mold and (2) the
difficulty in determining which of several disease-causing agents in
damp indoor environments may be responsible for the adverse health
effects. In this regard, the 2000 and 2004 Institute of Medicine
reports and the more recent reviews we examined identified the need for
additional research to address these and other uncertainties related to
the connection between exposure to indoor mold and adverse health
effects. For example, the 2004 Institute of Medicine report concluded
that there is a need for research to determine the health effects of
long-term exposure to the toxins that some molds can produce.
The 65 ongoing federal research activities on the health effects of
exposure to indoor mold conducted or sponsored by EPA, HHS, and HUD
address to varying extents 15 gaps in scientific data reported by the
Institute of Medicine. These gaps relate to the need to better define
any association between a wide range of specific potential adverse
health effects and exposure to indoor mold. Of the 65 research
activities, nearly 60 percent address asthma, and more than half
address measurement methods--that is, sampling and exposure assessment
methods for indoor mold. Some other important data gaps are being
minimally addressed. For example, 5 of the 65 research activities
examine the effects of human exposure to molds that produce toxins that
may cause a number of adverse health effects, and only 1 relates to
acute pulmonary hemorrhage in infants--a rare but life-threatening
condition that may be caused by exposure to mold. Further, identifying
and coordinating research priorities, and efforts to achieve them, are
particularly important given the wide range of research needs
identified by the Institute of Medicine reports, the number of federal
entities involved in conducting research on mold, and limited federal
resources. However, federal officials reported that fewer than half of
their ongoing research activities have involved coordination either
with other units in their agencies or other federal agencies. For
example, of the 36 ongoing research activities related to sampling and
measurement methods, only 14 are being coordinated to some extent.
Further, in many cases, research activities were only coordinated
within the agency conducting or sponsoring the research. Moreover,
although the Federal Interagency Committee on Indoor Air Quality could
provide a structured mechanism for coordinating research activities, it
does not serve this function. That is, instead of selecting specific
topics and tasks to advance scientific knowledge in the area of indoor
air quality--such as reviewing and prioritizing agencies' ongoing and
planned research in particular areas--the agendas for the committee
meetings are largely driven by the interests of the agencies'
individual committee representatives.
Despite the limitations of current scientific evidence in establishing
clear associations and causal linkages between a number of adverse
health effects and exposure to indoor mold, enough is known that
federal agencies have issued guidance to the general public about
health risks associated with exposure to indoor mold, how to minimize
mold growth, and how to mitigate exposure. For example, a majority of
the 32 guidance documents we reviewed issued by the Consumer Product
Safety Commission, EPA, FEMA, HHS, and HUD describe some common adverse
health effects, such as asthma attacks and upper respiratory tract
symptoms. However, the guidance documents inconsistently identify some
other health effects that may be less common. For example, only 6 of
the 32 documents warn that exposure to mold can lead to
hypersensitivity pneumonitis, a relatively rare but potentially serious
allergic reaction. In addition, most of the guidance documents offer
consistent strategies for minimizing the growth of indoor mold--for
example, keeping areas dry and promptly addressing moisture sources,
such as leaks or spills. Finally, a majority of the documents also
address mitigating exposure to indoor mold, including directions for
cleaning up mold and protective clothing and equipment to wear while
doing so. However, the guidance is somewhat inconsistent about which
cleaning agents to use--for example, some documents recommend using
bleach, a biocide that is toxic to humans, if the mold growth is due to
floodwater; some recommend bleach regardless of the cause of the mold;
and others recommend using detergent. Finally, most of the documents
warn that certain populations may be more sensitive to mold than
others, but only two provide specific recommendations about the varying
levels of protective clothing and equipment (such as gloves,
respirators, and eye and skin protection) that such populations should
use under various circumstances. As a result of some of these omissions
and inconsistencies, the public may be at risk of unnecessary exposure
to indoor mold.
To better ensure that federal research on the health effects of
exposure to indoor mold is effectively addressing research needs and
efficiently using scarce federal resources, we are recommending that
EPA use the Federal Interagency Committee on Indoor Air Quality to both
(1) help guide federal research priorities on the health effects of
indoor mold and coordinate information sharing on this topic and (2)
help agencies better ensure that their guidance to the public provides
sufficient information on health effects of exposure to indoor mold,
and how to minimize it, and does not conflict among agencies. We
provided a draft of this report to the Consumer Product Safety
Commission, EPA, FEMA, HHS, and HUD for the agencies' review and
comment. EPA generally agreed with our recommendations regarding its
use of the Federal Interagency Committee on Indoor Air Quality. With
the exception of FEMA, the agencies also provided technical comments
that we incorporated into the report, as appropriate.
Background:
Moisture is the primary factor leading to indoor mold growth. To grow
indoors, mold also needs temperatures above freezing levels--from 32 to
130 degrees Fahrenheit--and organic matter. The nutrients upon which
mold feeds are provided by house dust and many surface and construction
materials, such as wallpapers, textiles, wood, paints, and glues.
Because the appropriate temperature and necessary nutrients are common
in homes, mold growth can rapidly occur indoors when excessive moisture
or water accumulates as a result of, for example, floods and other
natural disasters; building design or construction flaws; and poor
building maintenance practices, such as not repairing leaking plumbing.
Moist conditions indoors may also foster the growth of other organisms
capable of causing adverse health effects, including bacteria,
cockroaches, and dust mites.
Mold growth may be particularly severe following natural disasters such
as hurricanes and flooding. The extent of the flooding after Hurricanes
Katrina and Rita in 2005 led to conditions supporting widespread mold
growth. Unlike other hurricane-impacted areas, where residents could
access their buildings relatively quickly after the flood event, many
residents in New Orleans were unable to access buildings for several
weeks because of prolonged flood inundation. According to a CDC survey,
an estimated 46 percent of homes in New Orleans and surrounding areas
had visible mold growth. Widespread indoor mold contamination can cause
adverse health effects in returning residents and make it more
difficult to rehabilitate houses for reoccupation. For example, in 2006
the Army Corps of Engineers noted that because of mold problems caused
by the extensive flooding, many residences that did not require
demolition would nonetheless need to be gutted--stripping the walls
down to the studs--before they could be renovated.[Footnote 7]
The Institute of Medicine has identified four possible levels of
connection between indoor mold and adverse health effects: sufficient
evidence of a causal relationship, sufficient evidence of an
association, limited or suggestive evidence of an association, and
inadequate or insufficient evidence to determine whether an association
exists. According to HHS, establishing a causal relationship with
adequate certainty requires several types of evidence, including (1)
epidemiologic associations, (2) experimental exposure in animals or
humans that leads to the symptoms and signs of the disease in question,
and (3) reduction in exposure that leads to reduction in the symptoms
and signs of the disease. HHS officials said that more data are needed
to establish a causative association between exposure to mold and some
illnesses because the vast majority of the studies conducted to date
have been only epidemiologic.
The federal government has responded to the uncertainty surrounding the
health effects of exposure to indoor mold by, among other things,
sponsoring reviews of the available scientific evidence. Committees of
the National Academies' Institute of Medicine have produced two reports
in the past several years that relate to the health effects of exposure
to indoor mold. For a 2000 report requested by EPA, Clearing the Air:
Asthma and Indoor Air Exposures, the Institute of Medicine assembled a
multidisciplinary committee to examine the relevant research pertaining
to asthma and the indoor environment, including, among many other
issues, the possible impact of indoor mold on asthma prevalence. For
its 2004 report requested by the CDC, Damp Indoor Spaces and Health,
another Institute of Medicine committee reviewed the scientific
literature to determine the connections among damp indoor spaces,
microorganisms such as mold, and a variety of human health effects.
This committee used a uniform set of categories to summarize its
conclusions regarding the evidence of association between various
health outcomes and exposure to indoor dampness or the presence of mold
or other agents in damp indoor environments. While research in this
field continues to evolve, both reports made recommendations for
additional research related to mold and other areas that remain
relevant--that is, the data gaps have not been resolved.
In addition to sponsoring reviews of the available scientific evidence,
federal agencies have the opportunity to share information on various
aspects of indoor air quality, including mold, through the Federal
Interagency Committee on Indoor Air Quality. Title IV of the Superfund
Amendments and Reauthorization Act of 1986 directed EPA, among other
things, to disseminate the results of its indoor air quality research
program and establish an advisory committee consisting of other federal
agencies.[Footnote 8] EPA serves as the executive secretary of the
Federal Interagency Committee on Indoor Air Quality, which fulfills
this advisory role. The committee is co-chaired by EPA, the Department
of Energy (DOE), the Consumer Product Safety Commission, the National
Institute for Occupational Safety and Health (NIOSH), and the
Occupational Safety and Health Administration (OSHA). Other federal
departments and agencies participate in the committee as members. In
1991, we recommended that the Administrator, EPA, work with other
members of the committee to clearly define in a charter the roles and
responsibilities of the agencies participating in the committee in
order to strengthen interagency coordination of indoor air research.
[Footnote 9] However, EPA has not implemented this recommendation.
Although federal agencies are engaged in a number of efforts to address
indoor mold, there are no federal or generally accepted health-based
standards for safe levels of mold, its components, or its products in
the air or on surfaces. In fact, neither EPA nor OSHA has established
health-based standards for airborne concentrations of mold or mold
spores indoors. Similarly, NIOSH has not set recommended exposure
limits for indoor mold or mold spores. Further, according to EPA
officials, the lack of federal regulation of airborne concentrations of
mold indoors is largely attributable to the insufficiency of data
needed to establish a scientifically defensible health-based standard.
EPA officials also emphasized that the agency lacks the authority to
establish airborne concentration limits for mold indoors. Legislation
to require EPA to take action with respect to indoor mold has been
introduced in Congress in the past but was not enacted. For example,
the proposed United States Toxic Mold Safety and Prevention Act, most
recently introduced in Congress in 2005, would have directed EPA to
promulgate standards for preventing, detecting, and remediating indoor
mold growth, among other things.
The presence of mold in homes and workplaces has led to numerous
lawsuits alleging personal injury or property damage. To obtain a
judgment that mold has caused personal injury, an individual must
persuade the court that the type of mold at issue is capable of causing
the individual's condition and that the mold actually caused the
condition in the specific case. Litigants generally use expert witness
testimony in an attempt to prove or disprove these points in court.
Courts use different standards to judge whether such testimony is
admissible. In some states, courts will admit such testimony only if it
is in accord with generally accepted consensus of the relevant
scientific community. In other states and in the federal courts, judges
independently evaluate the reliability of the evidence by weighing
several factors, only one of which focuses on the views of the relevant
scientific community. Many state courts use a mixture of these two
methods.
Insurance companies are frequently defendants in mold litigation, and
in response to the rise in cases early in the decade, many began
changing their policies to specifically exclude mold-related injuries
and property damage from coverage. For example, many insurance policies
now contain language stating that the insurance company "will not pay
for loss or damage caused by or resulting from ... rust, corrosion,
fungus, decay," and other conditions. As of 2006, the insurance
regulatory agencies in 40 states had approved mold-related exclusions.
Partly in response to a significant increase in mold litigation in the
early part of this decade, states began enacting legislation to address
various aspects of the mold problem. For example, in 2001 California
enacted the Toxic Mold Protection Act, which requires the state's
Department of Health Services to establish permissible mold exposure
limits for indoor air.[Footnote 10] In addition, in 2003, Texas passed
legislation requiring a mold remediation contractor to certify to a
homeowner that the mold contamination identified for the project had
been remediated as outlined in the mold management plan or remediation
protocol. Further, the Texas law requires owners selling property to
provide buyers with copies of each mold remediation certificate issued
for the properties the 5 preceding years. Examples of other state
legislative responses to mold issues include laws:
* requiring landlords to disclose to tenants information about the
health hazards associated with exposure to indoor mold;
* prohibiting litigation against a real estate agent acting on behalf
of a buyer or seller who has truthfully disclosed any known material
defects;
* establishing licensing requirements for individuals involved with
mold assessment and remediation; and:
* creating a group to study the effects of toxic mold.[Footnote 11]
Many Studies Associate Indoor Mold with Adverse Health Effects but Cite
the Need for Additional Research:
While the 2004 Institute of Medicine report, and reviews of the
scientific literature published subsequently, have found evidence
associating indoor mold with certain adverse health effects, the
evidence supporting an association between mold and other health
effects remains less certain. Two factors, in particular, pose
challenges for those attempting to determine the health effects of
exposure to indoor mold: valid quantitative methods of measuring
exposure are lacking, and a wide variety of other potential disease-
causing agents are likely to be present in damp indoor environments,
along with mold. According to the Institute of Medicine and recent
reviews of the scientific literature, further research is required to
advance the understanding of the relationships between dampness, indoor
mold, and human health.
While Mold Is Associated with Certain Adverse Health Effects, Evidence
for Others Is Less Certain:
The 2004 Institute of Medicine report, Damp Indoor Spaces and Health,
found sufficient evidence of an association between exposure to indoor
mold and certain adverse health effects--that is, an association
between the agent and the outcome has been observed in studies in which
chance, bias, and confounding factors can be ruled out with reasonable
confidence. These health effects include:
* upper respiratory tract symptoms, including nasal congestion,
sneezing, runny or itchy nose, and throat irritation;
* exacerbation of pre-existing asthma;
* wheeze;
* cough;
* hypersensitivity pneumonitis in susceptible persons; and:
* fungal colonization or opportunistic infections in immune-compromised
persons.
Of these health effects, the upper respiratory tract symptoms
associated with allergic rhinitis are the most common, according to the
American Academy of Pediatrics.[Footnote 12] In addition, the
association between indoor mold and exacerbation of asthma symptoms is
a particularly significant public health concern because asthma is the
most common chronic illness among children in the United States and one
of the most common chronic illnesses overall, according to the
Institute of Medicine's 2000 report, Clearing the Air: Asthma and
Indoor Air Exposures. Importantly, mold can affect certain populations
disproportionately. For example, the 2004 Institute of Medicine report
found sufficient evidence of an association between exposure to the
mold genus Aspergillus and serious respiratory infections in people
with severely compromised immune systems (such as chemotherapy patients
and organ transplant recipients). This report also found sufficient
evidence of an association between exposure to indoor mold and
hypersensitivity pneumonitis--a relatively rare but potentially serious
allergic reaction--in susceptible persons. In addition to these more
established health effects, this report also found limited or
suggestive evidence of an association between indoor mold and lower
respiratory illness (for example, bronchitis and pneumonia) in
otherwise healthy children.
Most of the 20 reviews of the scientific literature published from 2005
to 2007 that we examined generally agreed with the conclusions of the
2004 Institute of Medicine report.[Footnote 13] However, two of the
reviews characterized the relationship between exposure to indoor mold
and certain of the above health effects more strongly. The American
Academy of Pediatrics stated in its 2006 report that epidemiologic
studies consistently support causal relationships between exposure to
mold and upper respiratory tract symptoms and exacerbation of pre-
existing asthma. The American Academy of Pediatrics also said that
epidemiologic studies support a causal relationship between exposure to
mold and hypersensitivity pneumonitis in susceptible persons.[Footnote
14] Moreover, a 2007 meta-analysis[Footnote 15] sponsored by EPA and
DOE found that building dampness and mold are associated with increases
of 30 percent to 50 percent in a variety of health outcomes, such as
upper respiratory tract symptoms, wheeze, and cough. The authors
concluded that these associations strongly suggest these adverse health
effects are caused by dampness-related exposures.[Footnote 16]
According to the 2004 Institute of Medicine report, the evidence of an
association between exposure to indoor mold and a variety of other
health effects, however, is inadequate or insufficient--that is, the
available studies are of insufficient quality, consistency, or
statistical power to permit a conclusion regarding the presence of an
association. The health effects for which there is inadequate or
insufficient evidence of an association with indoor mold include:
* acute idiopathic pulmonary hemorrhage in infants;
* airflow obstruction in otherwise-healthy persons;
* cancer;
* chronic obstructive pulmonary disease;
* development of asthma;
* fatigue;
* gastrointestinal tract problems;
* inhalation fevers not related to occupational exposures;
* lower respiratory illness in otherwise-healthy adults;
* mucous membrane irritation syndrome;
* neuropsychiatric symptoms;
* reproductive effects;
* rheumatologic and other immune diseases;
* shortness of breath; and:
* skin symptoms.
Most of the recent reviews of the literature we examined generally
concurred with these Institute of Medicine conclusions as well,
although a few found a somewhat stronger relationship between indoor
mold and certain of the health effects listed above. For example, a
2007 review concluded that dampness and exposure to indoor mold can
exacerbate or may cause shortness of breath, among other health
effects.[Footnote 17] In addition, other reviews differed in their
conclusions regarding the link between exposure to indoor mold and
acute idiopathic pulmonary hemorrhage in infants, the sudden onset of
pulmonary hemorrhage in a previously healthy infant. This condition was
reported among a group of infants from the same part of Cleveland,
Ohio, in the 1990s and attributed by some researchers to exposure to
indoor mold. Five of the reviews we examined contained conclusions
about acute idiopathic pulmonary hemorrhage in infants and children.
Two concluded that mold has not been proven to cause this condition.
[Footnote 18] However, a third review--the American Academy of
Pediatrics 2006 report--said that although a causal relationship has
not been firmly established, a variety of studies have provided some
evidence that such a relationship is plausible. The fourth review said
that the association between acute idiopathic pulmonary hemorrhage in
infants and children and mold is strong enough to justify removing them
from moldy environments or cleaning up these spaces,[Footnote 19] and
the fifth review reiterated this recommendation.[Footnote 20]
Some of the health effects for which the evidence remains unclear (for
example, fatigue and acute idiopathic pulmonary hemorrhage in infants)
have been attributed to reactions to toxins, or "mycotoxins," that can
be produced by certain types of mold that grow indoors. The reviews we
examined were largely consistent in their interpretations of the
evidence for the role of mycotoxins in relation to adverse health
effects. The Institute of Medicine reported in 2004 that (1) exposure
to mycotoxins can occur via inhalation, contact with the skin, and
ingestion of contaminated food and (2) research on Stachybotrys
chartarum (a species of indoor mold that can produce mycotoxins)
suggests that effects in humans may be biologically plausible. However,
the report also noted that the effects of chronic inhalation of
mycotoxins require further study and that additional research must
confirm the observations on Stachybotrys chartarum before a more
definitive conclusion can be drawn. Among the more recent reviews we
examined that specifically addressed mycotoxins, five reached a similar
conclusion--that is, that the current evidence is inconclusive or
limited.[Footnote 21] However, one review suggested that it is likely
that mycotoxins play some role in building-related disease, including
exacerbation of pre-existing asthma.[Footnote 22] On the other hand,
another recent review cast doubt on the health effects of mycotoxins in
one set of circumstances--specifically, the review concluded that it
was improbable for mycotoxins to cause negative health effects through
a toxic mechanism when individuals inhale mycotoxins in nonoccupational
settings (such as homes). This review, however, explicitly stated this
conclusion did not address adverse health effects of mycotoxins that
may be caused by immune-mediated mechanisms or stem from exposure in
occupational settings or by ingestion.[Footnote 23]
Two Key Factors Pose Challenges for Determining the Health Effects of
Exposure to Indoor Mold:
According to the 2004 Institute of Medicine report, two key issues
largely contribute to the scientific data gaps regarding the
relationship between mold and adverse health effects: (1) valid
quantitative methods of measuring exposure are lacking, and (2) a wide
variety of potential disease-causing agents are likely to be present in
damp indoor environments, which makes it difficult to link health
effects with specific agents. Without standardized, quantitative
methods to measure exposure, it is difficult to compare exposure levels
across studies or between individuals with and without symptoms of
adverse health effects. This makes it challenging to draw valid and
consistent conclusions on the health effects of indoor mold.
No single or standardized method to measure the magnitude of exposure
to mold has been developed. Consequently, researchers use a variety of
methods to assess exposure, each of which has advantages and
disadvantages. For example, most studies use an indirect method to
assess exposure--occupant questionnaires about the presence of dampness
or mold in a building--according to the 2004 Institute of Medicine
report. Other exposure assessment methods include personal monitoring,
which involves measuring agent concentrations with monitors carried by
individuals, and quantifying biologic response markers in bodily
fluids. Another method of exposure assessment is to collect
environmental samples of indoor air, dust, or building materials such
as wallboard and quantitatively analyze the presence of mold (or its
components or products) in the samples. In addition to the various
methods that can be used to collect and analyze samples, environmental
sampling for mold is complicated by the fact that concentrations of
mold (particularly in the air) can vary over time and across an indoor
environment. Moreover, many newly developed sampling methods are not
commercially available or well-validated.
The second issue contributing to limitations in the understanding of
the relationship between mold and a number of adverse health effects is
the variety of potential disease-causing agents--including many species
of mold and other biological agents, such as bacteria or dust mites--
that are likely to be present in damp indoor environments. The number
of such agents makes it difficult to know which ones are specifically
responsible for the adverse health effects attributed to these
environments. For example, of the approximately 1 million species of
mold, there are about 200 species of mold to which humans are routinely
exposed, although not all of these are commonly identified in indoor
environments, and not all types pose the same hazards to human health.
The mold genus Alternaria, for instance, which has been found in moldy
building materials, has been linked to severe asthma. Furthermore,
several different components or products of mold, such as mycotoxins,
may function as disease-causing agents in indoor environments. The
release of these mold components or products varies with environmental
and other factors, and the individual roles they may play in adverse
health effects are not fully understood. People are also exposed to
mold in outdoor environments, where the concentrations, while they vary
considerably, are usually higher than those found indoors. While the
specific species of mold that grow indoors may differ from those found
outdoors, the potential for outdoor exposure further complicates
efforts to determine the relationship between adverse health effects
and indoor exposure to mold.
In addition to mold, damp indoor areas can support other biological
agents that may result in adverse health effects, including bacteria,
dust mites, cockroaches, and rodents. Dust mites, for example, are
known to cause the development of asthma. Damp conditions may also lead
to potentially harmful chemical emissions from building materials and
furnishings. For example, excessive indoor humidity may increase the
release of formaldehyde, a probable human carcinogen, from building
materials such as particle board. Exposure to formaldehyde has been
linked to some of the same health effects that have been attributed to
indoor mold, such as wheezing, coughing, and exacerbation of asthma
symptoms, as well as more severe effects.
Additional Research Is Needed to Better Address Uncertainties Related
to the Connection between Health Effects and Exposure to Indoor Mold:
The 2000 and 2004 Institute of Medicine reports and other recent
reviews of the scientific literature have identified numerous areas
where further research is required to advance the understanding of the
relationships between dampness, indoor mold, and human health.[Footnote
24] Specifically, the health effects of the components and products of
mold require further study. The effects of mycotoxins in particular
remain poorly understood, partly because most of the toxicologic
studies on mycotoxins have examined the acute (or short-term) effects
of high levels of exposure to mycotoxins in small populations of
animals. To address these limitations, the 2004 Institute of Medicine
report recommended that studies be conducted to help determine, among
other things, (1) the effects of chronic (or long-term) exposures to
mycotoxins via inhalation and (2) the dose of mycotoxins required to
cause adverse health effects in humans. This report also recommended
research on a particular species of toxin-producing mold, Stachybotrys
chartarum, and on the relationship between mold and dampness and acute
idiopathic pulmonary hemorrhage in infants. In its 2000 report, the
Institute of Medicine also called for additional research related to
mold particles as allergens and research to evaluate the association of
dampness and mold with the development of asthma. As can be expected as
research progresses over time, some of the more recent reviews we
examined made additional or more specific research recommendations
related to mycotoxins and other components and products of mold. A
number of lawsuits alleging serious health effects as a result of
exposure to indoor mold have involved exposure to mycotoxins,
underscoring the need for additional research in this area.
In addition, research to develop, improve, and standardize methods for
assessing exposure to mold is a high priority for understanding the
health effects of mold, according to the Institute of Medicine's 2004
report. Specifically, the report recommends additional research to
validate and refine existing exposure assessment methods for mold,
including procedures for collecting and analyzing environmental
samples. Such research would facilitate comparison of results within
and across epidemiological studies and help better define the
relationships between mold and adverse health effects. In addition,
improved methods for measuring exposure to specific components of mold
would help efforts to study the roles of these agents in causing
adverse health effects.
The 2004 Institute of Medicine report also identified the need for
additional research on mold mitigation strategies and measures to
prevent or reduce dampness, the growth of indoor mold, and exposure to
mold. These strategies could include remediation activities, building
renovation, and changes in building operation or maintenance practices.
For example, research is needed to develop standardized, effective
cleanup methods to mitigate mold growth after flooding and other
catastrophic water events. In addition, the 2004 Institute of Medicine
report recommended research to assess how effectively personal
protective equipment, such as gloves, safety goggles, and respirators,
reduces exposure to mold during mitigation activities.[Footnote 25]
Research in these areas is important to help ensure that (1) mold
mitigation actually improves unhealthy conditions in indoor
environments and (2) protective equipment used during remediation
successfully reduces the amount of mold to which workers and building
occupants are exposed.
Federal Research Activities on the Health Effects of Indoor Mold
Address Data Gaps to Varying Degrees; Limited Planning and Coordination
of the Activities May Reduce Their Ability to Close Data Gaps:
Federal research activities address gaps in scientific data on the
health effects of indoor mold identified by the Institute of Medicine
to varying degrees, with a large number focusing on two areas in
particular--asthma and measurement methods. The impact of this research
portfolio may be reduced, however, by limited planning and
coordination.
Federal Research Activities on Mold Largely Address Asthma and
Measurement Methods:
EPA, HHS, and HUD officials reported that they were conducting or
sponsoring 65 mold research activities as of October 1, 2007: HHS
reported 43 ongoing research activities; and EPA and HUD reported 15
and 7, respectively. The Institute of Medicine's 2000 and 2004 reports
identified a number of gaps in the research needed to more clearly
delineate any association between exposure to indoor mold and a number
of adverse health effects.[Footnote 26] As shown in appendix III, these
gaps may be grouped into 15 broad categories.[Footnote 27] Agency
officials reported that most of the individual federal research
activities address 2 or more of the 15 data gaps. Collectively, the
agencies indicated that their research activities address all of the 15
data gaps to varying extents--the number of research activities
addressing individual gaps ranged from 1 to 32 (see app. III).
Moreover, EPA, HHS, and HUD officials reported that 75 percent of their
mold research activities address at least one of five particular data
gaps--three of which relate to asthma, and two of which relate to
sampling and measurement methods. These five data gaps are as follows:
* Identify environmental factors that either lead to the development of
asthma or precipitate symptoms in subjects who already have asthma
using good measures of fungal exposure.
* Determine the association of dampness problems with asthma
development and symptoms by researching the causative agents (e.g.,
molds, dust mite allergens) and documenting the relationship between
dampness and allergen exposure.
* Advance the understanding of specific bioaerosols (small airborne
particles) in relation to asthma by studying the epidemiology of
building-related asthma in problem buildings where there are excess
chest complaints among occupants in comparison to buildings where there
are not complaints; or provide exposure-response studies of many
building environments and populations.
* Improve sampling and exposure assessment methods for mold and its
components (for example, by conducting research that will lead to
standardization of protocols for sample collection, transport, and
analysis or developing or improving methods of personal airborne
exposure measurement, DNA-based technology, or assays for bioaerosols,
etc.)
* Develop standardized metrics and protocols to assess the nature,
severity, and extent of dampness and effectiveness of specific measures
for dampness reduction.
Overall, agency officials reported that 38 of the ongoing projects--or
nearly 60 percent--address asthma. In this respect, the federal mold
research portfolio for EPA, HHS, and HUD, ongoing as of October 1,
2007, appears to be weighted toward addressing research gaps identified
in the Institute of Medicine's 2000 report, Clearing the Air: Asthma
and Indoor Air Exposures. The research activities federal officials
reported as addressing one or more of the asthma-related research gaps
include studies using animals. For example, one focuses on gestational
exposure in mice to mold extracts and the effect this exposure has on
the development of allergy or asthma in adult life; one assesses in
mice the relative allergenic potency of molds statistically more common
in water-damaged homes; and another is developing animal models (using
mice and rats) to evaluate the pulmonary inflammatory response to mold
products collected from indoor dust samples from buildings where people
have reported respiratory symptoms and from buildings with no reported
health complaints.[Footnote 28] Other asthma-related research
activities are aimed, for example, at better understanding the
relationship between respiratory symptoms and exposure to water-damaged
homes in posthurricane New Orleans and at evaluating the respiratory
health of staff and students attending schools that expose them to
varying degrees of dampness.[Footnote 29] (Summaries of the 65 research
activities conducted or sponsored by EPA, HHS, and HUD are provided in
a supplement to this report--see [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-984SP].)
Many of the projects that address asthma also address sampling and
measurement methods. Research that provides high-quality, consistent
methodologies for sampling and measuring mold is essential to progress
in evaluating the health effects of exposure to mold. For example, the
Institute of Medicine reported in 2004 that evidence of an association
between exposure to mold and 15 specific health effects is inadequate
or insufficient to permit a conclusion regarding the presence of an
association because of the insufficient quality, consistency, or
statistical power of the available studies. This report, Damp Indoor
Spaces and Health, identified the need for standardized metrics and
protocols. The Institute's earlier 2000 report that focused on asthma
had previously identified the need to improve exposure assessment
methods for mold.
Overall, EPA, HHS, and HUD reported 36 research activities that address
sampling and exposure assessment methods or standardized metrics and
protocols. While a number of the research activities address these
measurement methods as part of investigations focusing on specific
health effects or other issues related to indoor mold, several focus
solely or primarily on developing measurement methods. For example,
HHS's NIOSH is working to develop biomarkers of mold exposure to lead
to objective, standardized measures of exposure to support reproducible
and comparable analyses in health studies, including large-scale
epidemiological studies.[Footnote 30] HHS's National Institute of
Environmental Health Sciences has three separate studies: (1)
evaluating available biomarkers of exposure and effect for specific
molds that may cause systemic toxicity, (2) developing tests for
allergenic mold species and toxin-producing molds found in water-
damaged homes that can be used to objectively assess mold exposure in
buildings, and (3) testing the feasibility of a flexible and low-cost
measurement method for allergens, including mold.[Footnote 31] Another
example of ongoing research focusing on mold identification is HHS's
CDC work to develop and validate DNA-based methods for identification
and fingerprinting medically important molds because "the absence of a
robust species/strain identification scheme has hampered the rapid
identification of novel species and the associated burden of disease."
[Footnote 32]
EPA and HUD also reported working on DNA-based assessment methods.
Specifically, agency officials reported ongoing work using, in part, a
DNA-based method for analyzing 36 species of mold that EPA developed,
patented, and has licensed commercial laboratories to perform. Working
with HUD, EPA used this method to develop a standard sampling and
analytic process that then led to the development of the Environmental
Relative Moldiness Index (ERMI) scale for U.S. homes. According to EPA,
this index provides a simple, objective evaluation of the mold burden
in a home. EPA reported ongoing epidemiological studies using the ERMI
scale aimed at determining if the ERMI values can be used to understand
the risk of asthma or related respiratory symptoms.[Footnote 33]
While most of the 65 ongoing research activities involving indoor mold
are addressing asthma and critical data gaps in sampling and
measurement methods identified in the 2000 and 2004 Institute of
Medicine reports, some other important data gaps identified in the 2004
report are being studied to a lesser degree than the gaps identified in
the 2000 report. Notably, of the 15 data gaps identified in these
reports, agency officials reported that only 9 research activities
address to some extent 3 of the gaps identified in the 2004 report that
follow.[Footnote 34]
* Research the relationship between mold and dampness and acute
pulmonary hemorrhage or hemosiderosis in infants.
* Determine the effects of human exposure to Stachybotrys chartarum in
indoor environments.
* Determine, for mycotoxins, the dose required to cause adverse health
effects in humans via inhalation and skin (dermal) exposure; techniques
for detecting and quantifying mycotoxins in tissues; or the effects of
long-term (chronic) exposures to mycotoxins via inhalation.
Officials from EPA, HHS, and HUD reported only one research activity
examining the relationship between mold and dampness and acute
pulmonary hemorrhage or hemosiderosis in infants--a rare but serious
health condition whose relation to exposure to indoor mold remains
unsettled, as discussed earlier. This research is aimed at developing
quantitative biomarkers for the toxin-producing mold species
Stachybotrys chartarum--a mold that has been implicated in cases of
acute pulmonary hemorrhage in infants--to facilitate epidemiological
and other studies examining mold-related health effects.[Footnote 35]
Sponsored by HHS's National Institute of Environmental Health Sciences,
this research will support but does not directly address the 2004
Institute of Medicine's recommendation for research on the relationship
between mold and dampness and acute pulmonary hemorrhage in infants.
Specifically, the Institute of Medicine report concluded that the role
of Stachybotrys chartarum in cases of acute idiopathic pulmonary
hemorrhage in infants that had been studied remained controversial and
encouraged HHS's CDC to pursue surveillance and additional research on
the issue to resolve outstanding questions because this condition has
serious health consequences. The Institute of Medicine further stated
that epidemiologic and case studies should take a broad-based approach
to gather and evaluate information on exposures and other factors that
would help identify the causes of acute idiopathic pulmonary hemorrhage
in infants, including dampness and agents associated with damp indoor
environments and environmental tobacco smoke, among others. According
to CDC officials, the agency is not currently conducting either
epidemiological or case studies on acute pulmonary hemorrhage in
infants.[Footnote 36]
Five research activities that federal agencies reported were addressing
the toxin-producing mold species Stachybotrys chartarum were: part of
two studies on asthma; a study to develop tests for allergenic mold
species and toxin-producing molds found in water-damaged homes and a
study to develop quantitative biomarkers to assist epidemiological and
other research examining mold-related health effects (both discussed
above as also addressing other data gaps); and a follow-up study
analyzing archived serum and house dust samples for Stachybotrys
chartarum and related mycotoxins in the context of the clinical symptom
profiles previously gathered on the study participants.[Footnote 37]
The research gap on the health effects of exposure to mycotoxins--
toxins that can be produced by certain types of mold and may
potentially cause adverse health effects--is being addressed to some
extent by four research activities, according to agency officials. One
of the activities will assess the potential for molds found in damp or
water-damaged buildings to cause nervous system or systemic toxicity. A
second activity aims to develop improved sensors for detecting
mycotoxins in contaminated food and feed to support proper remedial
actions.[Footnote 38] A third activity is using an animal model to
understand the disease pathogenesis of hypersensitivity pneumonitis--a
relatively rare but potentially serious allergic reaction in
susceptible persons that can, in its chronic form, result in permanent
lung damage.[Footnote 39] Lastly, a fourth activity is a study of the
mechanistic indicators of childhood asthma that uses air, biologic and
clinical measures as well as molecular biology, chemistry, and gene
technologies to identify factors that affect individual susceptibility
to asthmatic responses.[Footnote 40] EPA reported that while this study
is not directed at mold per se, the secondary data being collected
could address some other research activities that the Institute of
Medicine reports identified as relating to sampling and exposure
assessment and mycotoxins, among others.
Finally, EPA and HHS reported they had completed 42 mold-related
research activities between January 1, 2005, and September 30, 2007.
[Footnote 41] In general, these activities address topics such as
asthma and sampling and measurement methods, reflected in the portfolio
of agencies' ongoing research activities. Information on the recently
completed research activities is provided in a supplement to this
report (see [hyperlink, http://www.gao.gov/cgi-bin/getrpt?GAO-08-
984SP]).
Limited Planning and Coordination of Research Activities May Affect
Their Ability to Close Data Gaps on the Health Effects of Exposure to
Indoor Mold:
While the information on research activities relating to the health
effects of exposure to indoor mold provides some insight into the
extent to which federal agencies are addressing scientific data gaps
identified by the Institute of Medicine in 2000 and 2004, the extent to
which these ongoing research activities will effectively advance
scientific knowledge in these areas is not clear. Specifically, the
research is not guided by an overarching strategic plan or entity that
would help agencies work together to identify their research priorities
on the health effects of mold. Instead, agencies generally determine
independently which research activities they will support using a
variety of criteria. This lack of clearly articulated, common research
goals is exacerbated by the limited intra-and inter-agency planning and
coordination of research activities among federal agencies. Specific
information that highlights planning and coordination limitations
follows.
Selection criteria for research the agencies sponsor are not always
linked to identified data gaps. Several EPA, HHS, and HUD officials
indicated that selection of priorities for research can be based on
various considerations, including agency expertise in a particular area
or input from external stakeholders. For example, both HHS and HUD
officials noted that ideas for research priorities can come from former
grantees.
A key planning document that several EPA officials reported consulting
is now outdated. Specifically, the agency's 2005 Program Needs for
Indoor Environments Research document,[Footnote 42] which outlines the
agency's research needs for the indoor environment and mold, among
other topics, reflects input from the Institute of Medicine's 2000
report but not the more recent 2004 report, which also identified a
number of important data gaps. EPA officials told us that the agency's
research related to asthma and mold's health effects has been a
priority, in part, because this topic was identified in the 2000
Institute of Medicine report, Clearing the Air: Asthma and Indoor Air
Exposures.
Some officials stated that the 2004 Institute of Medicine report on
indoor mold has not influenced their research priorities on this topic.
While officials at HHS's NIOSH reported that the Institute of
Medicine's 2004 report had a "major impact" on what indoor
environmental quality research their institute conducts, HHS officials
from two of the National Institutes of Health noted that this report
did not affect their institutes' internal priorities in this area. One
official stated that while the publication of this report did not
change any of their internal priorities, it may have encouraged
external interest in mold research.
The process that NIH uses to fund outside research may also limit the
extent to which identified data gaps are addressed. Specifically,
federal officials from three different NIH institutes[Footnote 43] that
sponsored 29 of the 65 ongoing research activities as of October 1,
2007, reported that 19 were unsolicited--that is, they were initiated
by investigators outside the institutes.[Footnote 44] Most NIH-funded
research is initiated by such investigators. These investigators
submitted research proposals that were of interest to them and thus
were not necessarily responsive to specific agency priorities. Along
these lines, officials at one institute said they generally fund indoor
mold research only because of outside investigators' interest.
Unsolicited proposals are ranked for funding through a rigorous peer-
review process for, among other things, scientific merit and the
significance of the research.[Footnote 45] While the specific topic of
the research is considered in light of its potential impact on public
health during peer review, NIH officials said that specific gaps
identified in the Institute of Medicine's report may well have a lower
significance relative to the three institutes' many other scientific
priorities. That is, while the three institutes do solicit research on
areas considered to be priorities, studies on the health effects of
exposure to indoor mold have generally not been in this category.
Less than half of the agencies' 65 ongoing research activities are
being coordinated, either within or outside their agencies.
Specifically, in responding to our survey of ongoing research
activities involving the health effects of indoor mold, EPA, HHS, and
HUD reported that 28 of their 65 research activities are being
coordinated (see fig. 1). In other work, we identified practices that
agencies should use when coordinating their activities, including (1)
defining and articulating a common outcome, (2) identifying and
addressing needs by leveraging each others' resources, and (3) agreeing
on agency roles and responsibilities.[Footnote 46] Especially when
agencies are conducting research activities addressing the same data
gap, coordination is important to ensure inappropriate duplication of
efforts does not occur and to best leverage limited federal resources.
Even in these cases, however, a significant number of activities are
not being coordinated. For example, of the 32 EPA, HHS, and HUD
research activities seeking to identify which environmental factors,
such as mold, contribute to the development or exacerbation of asthma,
federal officials reported that 18 activities are not being
coordinated. Similarly, agencies are not coordinating on 22 of 36
research activities related to sampling and measurement methods.
Figure 1: Coordination of Ongoing Federal Mold Research Activities
within the Agency or among Other Federal Agencies, as of October 1,
2007:
[See PDF for image]
This figure is a stacked vertical bar graph depicting the following
data:
Federal agency: EPA;
Number of research activities coordinated to some extent: 11;
Number of research activities not coordinated: 4.
Federal agency: HHS;
Number of research activities coordinated to some extent: 12;
Number of research activities not coordinated: 31.
Federal agency: HUD;
Number of research activities coordinated to some extent: 2;
Number of research activities not coordinated: 5.
Source: GAO analysis of EPA, HHS, and HUD survey data.
Note: HHS officials reported coordinating three research activities
with external organizations only. These activities are listed as not
coordinated in this figure.
[End of figure]
Further, the coordination activities reported by federal officials vary
widely. In some cases, the federal officials we surveyed reported
internal and external coordination on a specific research activity. For
example, an EPA official noted that his unit conducted one of its
research activities in conjunction with another unit within the agency,
provided updates regarding the activity to another unit, and
collaborated with another federal agency to write papers based on this
research. Coordination was more limited in other cases. Specifically,
in many cases, research activities were only coordinated within the
agency--and often, with only one other unit within the agency. For
example, one NIOSH official reported that, for one activity, his unit
coordinated with another unit within NIOSH by supplying certain
instruments.
Importantly, while agencies sometimes coordinate on individual research
activities, we did not identify any sustained efforts to coordinate
agencies' indoor mold research priorities. In the few instances in
which officials reported that they coordinated with others on research
priorities, it appeared that these partnerships did not specifically
address mold-related priorities. For example, while EPA officials told
us that they recently met with officials from HHS's CDC to discuss
mutual research opportunities related to the indoor environment, these
meetings did not address mold research priorities.
Federal agencies are not using the existing Federal Interagency
Committee on Indoor Air Quality as a forum to coordinate their research
activities on indoor mold. As discussed earlier, EPA serves as the
executive secretary of the Federal Interagency Committee on Indoor Air
Quality. We found that the committee addresses federal research
activities on indoor air quality on an informal basis. For example, our
analysis of the minutes of the 11 committee meetings from February 2005
to February 2008 shows that agency priorities related to indoor air
quality research, which could include research on mold, were discussed
only a few times. In one case, EPA officials described how their agency
had developed its research needs on indoor environments, which it
published in a document later in 2005 titled Program Needs for Indoor
Environments Research. In this case, EPA was not seeking input from
other agencies on research needs and priorities but rather was
informing other agencies of decisions EPA had made. Moreover, EPA, HHS,
and HUD officials who participate in committee meetings told us that
they had not discussed or sought input on their agency's mold-related
research priorities during committee meetings. Further, according to
committee meeting minutes, the information agency officials share at
committee meetings regarding their mold research is limited to
describing selected ongoing activities and issues related to their
funding. When mold-related research was discussed during the 3-year
period we reviewed, it was usually to provide an update on the status
of some individual research projects. In several instances, officials
also used the meetings to advertise the availability of funding for
research on indoor air quality issues, which could include research on
mold, or to announce the funding of mold-related research.
Currently, the committee holds 2-1/2 hour meetings in person and by
conference call three times a year that interested parties outside the
federal government can access. The agendas for the meetings are based
on input to EPA from member and nonmember agencies who propose topics
they would like to discuss. According to officials from one of the
participating agencies, the Consumer Product Safety Commission, the
Federal Interagency Committee on Indoor Air Quality had more
substantive discussions in the past on research projects, funding, and
which research priorities needed to be addressed than it does now.
The role of the Federal Interagency Committee on Indoor Air Quality has
changed over time. Established in response to congressional committee
direction in 1983, the committee, according to an EPA report,[Footnote
47] was to (1) coordinate federal indoor air quality research; (2)
provide for liaison and the exchange of information on indoor air
quality research among federal agencies, and with state and local
governments, the private sector, the general public, and the research
community; and (3) develop federal responses to indoor air quality
issues. According to a 1988 report on the structure and operation of
the committee, the committee comprised 16 member agencies and was co-
chaired by EPA, the Consumer Product Safety Commission, DOE, and HHS.
This report noted that considerable agreement existed among member
agencies that the primary role of the committee was to coordinate
federal indoor air activities. Further, coordination activities were
specified to include joint project planning and implementation;
contributions to and review of member agency indoor plans, reports, and
publications; communication on technical and nontechnical issues and
activities; and advising on, and fostering multiagency participation
in, indoor air program and research activities of individual agencies.
The committee met quarterly and had standing work groups covering
indoor air quality research areas to address a diverse range of indoor
air quality research issues, such as radon, formaldehyde, and allergens
and pathogens (which include molds). The work groups, which are no
longer active, were to coordinate research activities in these areas
and identify future indoor air quality research. EPA used the committee
to coordinate air quality research and assist in implementing the
indoor air quality research and development program established by
Congress in 1986. For example, in 1989 and 1999, EPA used the committee
to help it develop two reports that identified the individual research
activities on indoor air quality that federal agencies were conducting.
EPA has taken the lead in directing committee activities in the past,
such as chairing meetings, and this role continues today.
Federal Guidance to the General Public Identifies Various Health
Effects Associated with Exposure to Indoor Mold, as well as Strategies
to Limit It, Some of Which Are Inconsistent:
The Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD
guidance documents we reviewed identify health effects associated with
indoor mold in a residential setting but sometimes omit less common but
serious health effects. Most of the guidance documents recommend
similar strategies for minimizing mold growth. While guidance documents
that discuss mold mitigation offer consistent advice about detecting
mold, some provide conflicting information about cleaning agents and
the appropriate level of protective equipment individuals need when
mitigating mold in their homes.
Federal Guidance Cites Various Adverse Health Effects of Exposure to
Indoor Mold but in Some Cases Omits Less Common but Serious Effects:
A majority of the 32 documents we reviewed that provide guidance to the
general public on the health effects of indoor mold in their homes--
issued by the Consumer Product Safety Commission, EPA, FEMA, HHS,
[Footnote 48] and HUD--identify asthma and upper respiratory tract
symptoms as potential health effects. In addition, many of these
federal guidance documents cite unspecified allergic symptoms and skin
symptoms, such as dermatitis, rashes, and hives. The six adverse health
effects the Institute of Medicine found to be associated with indoor
mold in 2004 are included in the 32 guidance documents to varying
extents. However, all six adverse health effects are included in only
two guidance documents, although a majority of the guidance was issued
after the publication of the 2004 Institute of Medicine report.
[Footnote 49]
Further, only a few of the 32 guidance documents discuss adverse health
effects associated with mold that are less common but serious. Such
health effects include opportunistic infections or fungal colonization
in immune-compromised individuals and hypersensitivity pneumonitis, a
relatively rare allergic reaction in susceptible persons characterized
by fever, chills, dry cough, and a flulike feeling that can, in its
chronic form, result in permanent lung damage. Because these less
common but potentially serious adverse health effects are infrequently
cited in the guidance documents, some individuals consulting these
guidance documents may not take appropriate precautions when they are
exposed to indoor mold. Table 1 identifies the potential adverse health
effects cited in 6 or more of the 32 guidance documents we reviewed.
(App. V provides a list of the guidance documents we reviewed and
information on how to access them.)
Table 1: Potential Adverse Health Effects of Exposure to Indoor Mold
Cited in Six or More Guidance Documents, by Federal Agency:
Potential adverse health effects of exposure to indoor mold: Asthma,
asthma triggers, or asthma symptoms (such as episodes or attacks);
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 2;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 11;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 4;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 6;
Total number of documents citing the health effects: 27[B].
Potential adverse health effects of exposure to indoor mold: Upper
respiratory tract symptoms[C];
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 2;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 4;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 5;
Total number of documents citing the health effects: 21[B].
Potential adverse health effects of exposure to indoor mold: Eye
symptoms[D];
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 2;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 5;
Total number of documents citing the health effects: 20[B].
Potential adverse health effects of exposure to indoor mold: Skin
symptoms[E];
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 2;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 5;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 5;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 4;
Total number of documents citing the health effects: 16[B].
Potential adverse health effects of exposure to indoor mold: Allergies
or allergic reactions (symptoms not otherwise specified);
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 0;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 7;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 4;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 1;
Total number of documents citing the health effects: 15.
Potential adverse health effects of exposure to indoor mold: Wheeze;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 5;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 5;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 2;
Total number of documents citing the health effects: 13[B].
Potential adverse health effects of exposure to indoor mold: Cough;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 2;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 2;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 4;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 2;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 2;
Total number of documents citing the health effects: 10[B].
Potential adverse health effects of exposure to indoor mold: Difficulty
breathing or trouble breathing;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 2;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 4;
Total number of documents citing the health effects: 10[B].
Potential adverse health effects of exposure to indoor mold: Infections
(including those affecting people who have chronic lung disease);
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 0;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 6;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 0;
Total number of documents citing the health effects: 10.
Potential adverse health effects of exposure to indoor mold: Adverse
effects to the nervous system[F];
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 0;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 4;
Total number of documents citing the health effects: 8[B].
Potential adverse health effects of exposure to indoor mold: Shortness
of breath;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 3;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 0;
Total number of documents citing the health effects: 7[B].
Potential adverse health effects of exposure to indoor mold: Fungal
colonization or opportunistic infections in immune-compromised
individuals;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 0;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 1;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 0;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 5;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 1;
Total number of documents citing the health effects: 6[B].
Potential adverse health effects of exposure to indoor mold:
Hypersensitivity pneumonitis;
Number of documents reviewed, by agency: CPSC[A] (2): Number of
documents citing the health effects: 1;
Number of documents reviewed, by agency: EPA (12): Number of documents
citing the health effects: 4;
Number of documents reviewed, by agency: FEMA (8): Number of documents
citing the health effects: 0;
Number of documents reviewed, by agency: HHS (6): Number of documents
citing the health effects: 2;
Number of documents reviewed, by agency: HUD (6): Number of documents
citing the health effects: 1;
Total number of documents citing the health effects: 6[B].
Source: GAO analysis of selected federal guidance.
Notes: Other health effects stemming from exposure to indoor mold,
including fatigue, fever, dizziness, and gastrointestinal tract
problems, are cited in five or fewer guidance documents. Health effects
of exposure to indoor mold that are cited in only one document include
aches and pains, lung irritation, and death.
[A] Consumer Product Safety Commission.
[B] The sum of the guidance documents does not equal the total number
of guidance documents citing the health effect because two documents,
"Healthy Indoor Air for America's Homes" and "The Inside Story: A Guide
to Indoor Air Quality," were issued by multiple federal agencies.
[C] Symptoms can include nasal congestion, sneezing, runny/itchy/
stuffed up nose, throat irritation, and sore throat.
[D] Symptoms can include redness, watery eyes, irritation, and burning.
[E] Symptoms can include dermatitis, itching, rashes, hives, and
irritation.
[F] Symptoms can include headaches, memory loss, and mood changes.
[End of table]
Moreover, most of the federal guidance documents we reviewed describe
populations that may be particularly sensitive to indoor mold. However,
few of the documents identify all of the populations that should take
extra precautions to limit exposure to indoor mold. According to an HHS
guidance document, these populations include the immune-compromised as
well as those with asthma, chronic lung diseases, and allergies to
mold. Immune-compromised individuals include organ transplant
recipients, HIV patients, individuals with leukemia or lymphoma, and
those undergoing cancer chemotherapy or other immunosuppressant drug
therapies. HHS also recommends "due caution" for children, pregnant
women, and the elderly who are exposed to indoor mold. Although some of
the guidance documents identify several of these populations, some list
only one or two. As a result, individuals consulting these guidance
documents, especially those who are particularly vulnerable to mold
exposure, may not be fully apprised of the risks associated with such
exposure.
We recognize that the guidance documents we reviewed may address health
effects and particularly sensitive populations in varying levels of
detail because of differences in purpose and intended audience. For
example, several EPA guidance documents targeted toward particular
populations, such as teens, the elderly, and people with low literacy
levels, are limited in their scope and level of detail. In contrast,
HHS's document, Mold Prevention Strategies and Possible Health Effects
in the Aftermath of Hurricanes and Major Floods,[Footnote 50] which is
targeted to the general public as well as to public health officials,
includes a detailed discussion of numerous potential health effects
that may result from exposure to indoor mold. Although not all guidance
documents need to provide a comprehensive list of all of the potential
health effects of exposure to indoor mold, the information provided
should be sufficient to alert the public about potential adverse health
effects of exposure to indoor mold, highlight specific populations that
are particularly vulnerable to such exposure, and not conflict among
documents.
Guidance on Minimizing Indoor Mold Growth in Homes Is Generally
Consistent:
Most of the 32 guidance documents issued by the Consumer Product Safety
Commission, EPA, FEMA, HHS, and HUD that we reviewed describe how to
minimize indoor mold growth in the home. These documents generally
advise that residents reduce indoor moisture or humidity levels, and
their recommendations for doing so are generally consistent. A majority
of these guidance documents recommend that residents keep areas dry and
address moisture sources, such as leaks or spills. Some of the guidance
documents also recommend managing specific sources of moisture or
humidity by, for example, preventing water from entering the house,
ventilating and cleaning kitchens and baths to reduce moisture buildup,
and repairing and insulating pipes. In addition, a majority of the
documents recommend promptly drying wet items. Nearly half of the
documents that provide more specific recommendations note that porous
items, such as carpets, must be dried within 48 hours to avoid the
growth of mold and say that if more than 48 hours have elapsed, these
items should be discarded.
A number of the guidance documents that address strategies to minimize
indoor mold growth also advise residents to maintain indoor relative
humidity within specific ranges because high relative humidity can lead
to water condensation on indoor surfaces, such as walls and windows,
which can support mold growth. However, we note that the humidity
ranges specified by the guidance documents vary. For example, while all
the guidance documents that address relative humidity recommend
maintaining it at 60 percent or below, one FEMA document recommends
maintaining the relative humidity below 40 percent, and three guidance
documents issued by HHS recommend a relative humidity range between 40
percent and 60 percent.[Footnote 51] Such differences in guidance to
the public could cause some confusion about this aspect of minimizing
indoor mold growth.
Guidance on Mitigating Exposure to Indoor Mold Is Sometimes
Inconsistent about Cleanup Agents and Protective Clothing and
Equipment:
A majority of the guidance documents we reviewed provide information to
the public about mitigating exposure to indoor mold. Many of the
documents agree that if mold can be either seen or smelled, it should
be removed. Recommendations on detecting mold are broadly consistent
with information in a 2001 EPA report on mold mitigation in schools and
commercial buildings, which is cited by a number of the guidance
documents as a resource for mitigation of residential mold growth.
[Footnote 52],[Footnote 53] Further, the eight guidance documents that
discuss sampling or testing to measure the quantity or type of mold in
the indoor environment advise against it in most circumstances because
the results of such testing may not be useful. For example, one of
these documents explains that no standardized method exists either to
measure the magnitude of exposure to mold or to relate a particular
level of exposure to adverse health effects. Another guidance document
notes that it is generally not necessary to determine the species of
mold present.[Footnote 54] Finally, many of the guidance documents that
discuss mitigation note that if the mold is extensive (for example, if
it covers more than 25 square feet) or if it is found in the heating or
air conditioning systems, residents should consult further guidance,
such as EPA's Mold Remediation in Schools and Commercial Buildings, or
hire a professional contractor.
While a majority of the guidance documents we reviewed discuss how to
remove mold once a problem has been identified, there is some
inconsistency about which cleaning agents to use. For example, two
guidance documents recommend using detergent to clean mold. On the
other hand, HHS's Mold Prevention Strategies and Possible Health
Effects in the Aftermath of Hurricanes and Major Floods advises that
bleach may be warranted if the mold growth is due to floodwater, which
can be contaminated. Another guidance document, issued by EPA, also
advises that bleach be used when individuals who are particularly
susceptible to adverse health effects from mold, such as those who are
immune-compromised, are exposed to indoor mold. In contrast, six of the
guidance documents we reviewed, including several of the HHS documents,
recommend the use of bleach irrespective of certain populations or
whether the mold growth is due to flooding. According to EPA's 2001
report on mold mitigation, mold growing on hard (nonporous) surfaces
should be scrubbed with water and detergent and then vacuumed.[Footnote
55] This report recommends using bleach only in limited circumstances-
-such as when immune-compromised individuals are present--because
bleach, a biocide, is toxic to humans. These differences among guidance
documents could lead to confusion among the general public about the
safest and most effective way to remove mold. For example, if bleach is
not necessary in most instances, using it unnecessarily could lead to
avoidable problems, since bleach itself is a hazardous substance that
can generate toxic fumes if it is mixed with ammonia-based cleaners.
In addition, many of the guidance documents we reviewed discuss using
personal protective equipment while removing mold but, in some cases,
recommend different levels of protection for the general public as well
as for certain populations that may be more sensitive to mold exposure.
For example, as figure 2 shows, the guidance documents provide
inconsistent recommendations for the general public about wearing
respiratory protection, eye protection, and skin (dermal) protection
(such as long-sleeved shirts and long pants) for cleanups of limited
mold contamination.[Footnote 56]
Figure 2: Varying Levels of Personal Protection for Cleaning Limited
Mold Contamination, as Recommended by Selected Federal Guidance:
[See PDF for image]
This figure contains illustrations of varying levels of personal
protection for cleaning limited mold contamination, as recommended by
selected federal guidance. The illustrations provide the following
information:
Recommended by three guidance documents:
* gloves:
* respiratory protection.
Recommended by six guidance documents:
* gloves;
* respiratory protection;
* eye protection.
Recommended by six guidance documents:
* gloves;
* respiratory protection;
* eye protection:
* dermal protection.
Source: GAO analysis of selected federal guidance.
Note: The guidance variously defines "limited" mold contamination as
areas ranging from up to 10 square feet to up to 100 square feet.
[End of figure]
In addition, although 26 guidance documents caution that certain
populations may be more sensitive to mold, only 2 of them, issued by
HHS in 2005 and 2006, provide specific recommendations about the
varying levels of personal protection that such populations should use
under various circumstances. The HHS documents state that, when
inspecting or assessing damage, individuals with certain lung diseases
should wear respirators, while healthy individuals need no special
protection for these tasks. However, these documents warn that
individuals with "immunosuppression," such as those undergoing cancer
treatment or those who have leukemia or lymphoma, should wear a
respirator, gloves, and safety goggles when inspecting or assessing
damage. Further, those with "profound immunosuppression"--such as those
with HIV infection--should avoid all exposure to mold.
Guidance documents also provide inconsistent information about the
types of respiratory protection to use when cleaning up mold. Of the 15
guidance documents that recommend the use of respiratory protection
during cleanup, 6 list items such as dust masks, which do not protect
against mold because it can pass through them. Nine of the documents
suggest "N-95 respirators," which filter 95 percent of airborne
particles and can protect against inhaling mold. Moreover, only 3 of
the guidance documents recommending the use of N-95 respirators discuss
the need for proper fit--which could impact their effectiveness,
according to the HHS's NIOSH, the federal agency that approves these
respirators. Furthermore, only 1 guidance document, issued by HHS,
warns that respirator use may not be appropriate if an individual has a
pre-existing medical condition that makes it difficult to breathe while
wearing a respirator.
A number of agency officials said they revisit the content of their
guidance documents following significant new scientific discoveries or
in response to events such as major flooding or hurricanes. We note
that in the past few years, important updated information on the health
effects of exposure to indoor mold and ways to protect against
unnecessary exposure has been provided in three documents: the
Institute of Medicine's 2004 report and two HHS guidance documents on
mold issued in 2005 and 2006 in the aftermath of the hurricanes and
major floods on the Gulf Coast.[Footnote 57] Nevertheless, some of the
guidance documents we reviewed do not yet reflect important updated
information that these publications provide. Overall, despite the
useful information provided in the federal guidance we reviewed, some
omissions and inconsistencies could cause some individuals to be
exposed to indoor mold unnecessarily.
Conclusions:
While the current research activities on indoor mold conducted or
sponsored by EPA, HHS, and HUD address identified health-related
research gaps to varying degrees, these activities are largely
uncoordinated within and across agencies, and many are generated by
independent researchers rather than by agency solicitations for
specific research. This limited coordination contributes to the lack of
standardized, quantitative methods for measuring exposure to mold that
has impeded the advancement of knowledge about health effects and may
result in unnecessary duplication of research efforts. Without more
systematic coordination of planned and ongoing research activities,
future research may not be prioritized to best fill data gaps or be of
sufficient quality and consistency to more definitively support
conclusions about any associations to indoor mold and adverse health
effects. Specifically, the Institute of Medicine was unable to
associate a number of adverse health effects with exposure to mold
because the available studies were of "insufficient quality,
consistency, or statistical power to permit a conclusion regarding the
presence of an association."
An existing interagency committee--the Federal Interagency Committee on
Indoor Air Quality--could provide an effective vehicle for enhancing
the coordination of research activities. As the executive secretary and
co-chair, EPA guides the activities of this committee, which was
established in response to congressional direction to, among other
things, coordinate federal indoor air quality research and foster
information sharing among, for example, federal agencies and the
public. While the committee provides a forum for informal information
sharing, it has not been used in recent years to support systematic
coordination of federal research priorities or agendas for indoor air
research. Since the Federal Interagency Committee on Indoor Air Quality
was established in the 1980s, significant advances in communications
technologies, such as the Internet, have transformed the exchange of
information--for example, through Web pages and hyperlinks to documents
and Web sites. These communications advances can facilitate the
coordination among federal agencies, state and local governments, the
private sector, the research community, and the general public that the
Federal Interagency Committee on Indoor Air Quality was established to
accomplish.
Overall, the federal guidance documents we reviewed that provide
information to the general public about the health effects of exposure
to indoor mold, ways to minimize mold growth, and safe and effective
methods for cleaning up provide generally useful information. However,
some documents do not sufficiently advise the general public about some
potentially serious health effects, and others provide inconsistent
information about cleaning agents and appropriate protective gear.
Regarding protective gear, some documents do not provide information
about how populations that are particularly vulnerable to adverse
health effects should protect themselves. In fact, populations with
certain immunosuppression conditions should avoid exposure to mold but
many guidance documents do not state this. As a result, the public may
not be sufficiently aware of the health risks they or their family
members may face, and they may also be confused about how to approach
cleaning up mold in their homes.
Recommendations for Executive Action:
We recommend that the Administrator, EPA, use the Federal Interagency
Committee on Indoor Air Quality to accomplish the following two
actions.
* Help articulate and guide research priorities on indoor mold across
relevant federal agencies, coordinate information sharing on ongoing
and planned research activities among agencies, and provide information
to the public on ongoing research activities to better ensure that
federal research on the health effects of exposure to indoor mold is
effectively addressing research needs and efficiently using scarce
federal resources.
* Help relevant agencies review their existing guidance to the public
on indoor mold--considering the audience and purpose of the guidance
documents--to better ensure that it sufficiently alerts the public,
especially vulnerable populations, about the potential adverse health
effects of exposure to indoor mold and educates them on how to minimize
exposure in homes. The reviews should take into account the best
available information and ensure that the guidance does not conflict
among agencies.
Agency Comments and Our Evaluation:
We provided the Consumer Product Safety Commission, EPA, FEMA, HHS, and
HUD with a draft of this report and the related supplement (GAO-08-
984SP) for the agencies' review and comment. In its response, EPA
generally agreed with our recommendations that it use the Federal
Interagency Committee on Indoor Air Quality to, among other things,
help articulate and guide research priorities on indoor mold across
relevant federal agencies and help relevant agencies review their
existing guidance to the public on indoor mold to better ensure that it
sufficiently alerts the public about the potential adverse health
effects of exposure to indoor mold and educates the public on how to
minimize exposure in homes. In commenting on the draft report, HUD and
the Consumer Product Safety Commission also generally supported our
recommendations to EPA. FEMA did not provide comments on the report,
and HHS's comments did not address our recommendations to EPA. The
Consumer Product Safety Commission, EPA, HHS, and HUD also provided
technical comments on our report, and HHS provided a technical comment
on the supplement; their comments were incorporated, as appropriate.
As agreed with your office, unless you publicly announce the contents
of this report earlier, we plan no further distribution until 30 days
from the report date. At that time, we will send copies to the Acting
Chairman, Consumer Product Safety Commission; Administrator, EPA;
Administrator, FEMA; Secretary, HHS; Secretary, HUD; and other
interested parties. We will also make copies available to others upon
request. In addition, the report will be available at no charge on the
GAO Web site at [hyperlink, http://www.gao.gov].
If you or your staff have any questions about this report, please
contact me at (202) 512-3841 or stephensonj@gao.gov. Contact points for
our Offices of Congressional Relations and Public Affairs may be found
on the last page of this report. GAO staff who made major contributions
to this report are listed in appendix VI.
Sincerely yours,
Signed by:
John B. Stephenson:
Director, Natural Resources and Environment:
[End of section]
Appendix I: Objectives, Scope, and Methodology:
The objective of this review was to assess federal agencies' activities
to minimize and mitigate the health effects of exposure to indoor mold.
Specifically, we examined (1) what recent reviews of the scientific
literature have concluded about the health effects of exposure to
indoor mold; (2) the extent to which federal research addresses data
gaps related to the health effects of exposure to indoor mold; and (3)
what guidance key federal agencies are providing to the public on the
health risks of exposure to mold, and on minimizing and mitigating that
exposure, and the extent to which the guidance is consistent. Our
review focuses on the health effects and guidance to the general public
related to indoor mold in homes and does not address occupational
exposures or technical guidance documents targeted to specialized
audiences, such as medical professionals and emergency response
workers.
To determine what recent reviews of the scientific literature have
concluded about the health effects of exposure to indoor mold, we
primarily relied on the findings in the National Academies' Institute
of Medicine comprehensive report issued in 2004, Damp Indoor Spaces and
Health. To identify more recent reviews of the health effects of
exposure to indoor mold, we conducted a literature search. We searched
for reviews and meta-analyses, rather than individual studies,
published in English in 2005, 2006, and 2007, primarily using PubMed, a
bibliographic database service of the U.S. National Library of
Medicine. We conducted 19 different searches of PubMed using
combinations of the following search terms: mold, exposure, health,
indoor, glucan, microbial volatile organic compounds, mycotoxins,
ergosterol, hemolysins, fungal extracellular polysaccharides, fungal/
hyphal fragments, allergens, stachybotrys, acute ideopathic pulmonary
hemorrhage, acute pulmonary hemorrhage and infants, and hemosiderosis.
As part of these searches, we used PubMed's Clinical Queries option to
find Systematic Reviews, which cover a broad set of articles that build
consensus on biomedical topics. We also conducted a search for reviews
and meta-analyses using the search strategy "mold AND (exposure OR
indoor OR health)" in 15 other databases providing comprehensive
worldwide coverage of scientific and technical journals on relevant
topics. We reviewed the abstracts of all search results and obtained
copies of the publications for which no abstracts were available,
unless the available information indicated that the publication was
unrelated to our review. We evaluated the relevance of the abstracts
and publications and identified those that addressed the health effects
of exposure to indoor mold and its constituents or products, excluding
those that addressed dietary exposures, exposures in industrial or
agricultural settings, publications focused on yeasts, case studies of
mold in particular locations, and any publications that were clearly
not meta-analyses or reviews of the scientific literature. Twenty of
the reviews met our criteria (see app. II for a list of these reviews).
To assess the credibility, reliability, and methodological soundness of
these publications, a senior GAO analyst with a doctorate in
epidemiology reviewed each of the publications and any additional
methodological information obtained from the authors and considered
such factors as the bibliographies of evidence cited, the journals in
which the articles were published, and the extent to which they are
primary authors of other relevant articles. We did not examine the
references cited by these studies as part of our analysis. Some of the
reviews may be based on primary sources (for example, epidemiologic
studies), while others may also be based on sources that are themselves
reviews of the scientific literature (for example, the 2004 Institute
of Medicine report). We concluded that all 20 reviews were sufficiently
reliable for the purposes of this report.
We also used the 2004 Institute of Medicine report to help identify
areas where additional research is needed to address scientific data
gaps primarily related to the health effects of exposure to indoor mold
other than asthma, as well as the institute's 2000 report, Clearing the
Air: Asthma and Indoor Air Exposures, which focused on gaps related to
asthma. We conducted in-depth reviews of these reports, including their
methodology and conclusions, and we summarized the research needs they
identified related to the health effects of exposure to indoor mold.
To obtain information on federal research related to the health effects
of exposure to indoor mold, we conducted two surveys of officials at
the Environmental Protection Agency (EPA), the Department of Health and
Human Services (HHS), and the Department of Housing and Urban
Development (HUD) from November 2007 to May 2008. We used one survey to
(1) identify research activities related to the health effects of
indoor mold ongoing as of October 1, 2007, and (2) determine the extent
to which these research activities address the 15 data gaps identified
in the 2000 and 2004 Institute of Medicine reports related to the
health effects of exposure to indoor mold. Respondents completed a
survey for each individual research activity ongoing as of October 1,
2007. We also used this survey to identify the extent to which these
activities were coordinated both within and across agencies. We
conducted a second survey of these agencies to collect basic
information on their mold-related research activities completed from
January 1, 2005, to September 30, 2007. Overall, we received
information on 107 research activities from 37 EPA, HHS, and HUD
officials. We received responses to our surveys from all relevant
officials and agency entities. Summaries of the research activities
conducted or sponsored by EPA, HHS, and HUD are provided in a
supplement to this report (see [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-08-984SP]).
We surveyed officials at EPA, HHS, and HUD because of these agencies'
past and current participation in mold research. Specifically, we
identified these agencies based on federal reports to Congress
summarizing efforts to improve indoor air quality and interviews with
federal officials involved in this research, among other things. We
took a number of steps to ensure that our surveys would obtain reliable
information from the appropriate agencies and officials regarding
federal research activities on the health effects of exposure to indoor
mold. For example, to ensure that we sent surveys to all agency
officials involved in indoor mold-related research activities, we
provided audit liaisons and agency respondents with a list of the units
and officials in their agencies that we had identified as being
relevant. We also asked audit liaisons to verify that we had not
omitted any relevant units within their agencies and confirm whether
other agency officials identified during our interviews as potentially
involved in indoor mold-related research activities were involved with
relevant activities. When an audit liaison identified a new agency
respondent involved in indoor mold-related research activities, the
individual was provided with copies of our surveys. (See app. IV for
information on the units we contacted at these agencies.) We pretested
our survey questions by sending them to two researchers from EPA and
the National Institutes of Health (NIH) and incorporating their
feedback into the final surveys. To increase the response rate, we
followed up with agency officials to obtain responses from all relevant
parties. We also performed a series of reliability tests on the data we
received, including (1) examining agency submissions to exclude any
that were either duplicates or did not meet our criteria and (2)
checking for missing data or discrepancies. When we identified
discrepancies or inconsistencies in the data, we followed up with
relevant agency officials. In addition, we interviewed EPA, HHS, and
HUD officials to determine the extent to which they coordinate their
research projects and their priorities for mold-related research. To
assess the extent to which the Federal Interagency Committee on Indoor
Air Quality has been used to coordinate federal research activities
related to the health effects of exposure to indoor mold, we reviewed
relevant reports and the minutes of committee meetings dating from
February 2005 to February 2008, and we interviewed EPA and other
officials involved with the committee.
To determine what guidance key federal agencies are providing to the
general public on the health risks of exposure to indoor mold, and on
minimizing mold growth and mitigating exposure to mold in their homes,
and the extent to which the guidance is consistent, we focused our
review on the five federal agencies that provide information to the
general public on health risks and minimizing and mitigating exposure
to contaminants, including mold. The guidance we reviewed includes fact
sheets, brochures, booklets, and Web pages.[Footnote 58] Specifically,
we reviewed guidance on the health effects of mold in a residential
setting issued by the Consumer Product Safety Commission, EPA, HUD,
HHS, and the Federal Emergency Management Agency (FEMA) that was
identified primarily through online searches of federal Web sites and
interviews with relevant program officials.[Footnote 59] We selected
guidance to the general public that addresses health effects associated
with indoor mold using a nonprobability sample.[Footnote 60] We did not
include technical documents targeted to specialized audiences, such as
medical professionals or emergency response workers.[Footnote 61] Of
the 78 guidance documents that met our initial criteria, we selected 32
for detailed review on the basis of their content, purpose, and the
extent to which they specifically addressed indoor mold. (In some
cases, the documents broadly address indoor air contaminants but only
briefly mention mold.) Specifically, of the 34 mold-related guidance
documents FEMA issued to the general public responding to specific
disasters since 2004, we selected 8 for our review; we excluded the
other 26 because they contain essentially similar information. Further,
we included in our review the 8 guidance documents issued by the
Consumer Product Safety Commission and HUD that address health effects
associated with indoor mold; however, we excluded some guidance
documents issued by EPA and HHS primarily because they were similar to,
and thus duplicative of, other documents already included in our
review. We provided agency officials with an opportunity to review our
list of guidance documents and suggest additional documents for
inclusion in our review. We added relevant documents, as suggested.
(See app. V for the guidance documents included in our review.)
Additionally, we interviewed officials from the five agencies issuing
the guidance to determine their procedures for developing and issuing
guidance documents. The guidance documents we analyzed are publicly
available and can be accessed through the agencies' Web sites.
We conducted this performance audit from January 2007 to September 2008
in accordance with generally accepted government auditing standards.
Those standards require that we plan and perform the audit to obtain
sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that
the evidence obtained provides a reasonable basis for our findings and
conclusions based on our audit objectives.
[End of section]
Appendix II: Recent Reviews of the Health Effects of Mold:
The following list of recent reviews of the health effects of mold
includes two Institute of Medicine reports and 20 other reviews.
Borchers A.T., Chang C., Keen C.L., and M.E. Gershwin. "Airborne
Environmental Injuries and Human Health." Clinical Reviews in Allergy
and Immunology, vol. 31, no. 1 (2006): 1-102.
Bush R.K., Portnoy J.M., Saxon A., Terr A.I., and R.A. Wood. "The
medical effects of mold exposure." The Journal of Allergy and Clinical
Immunology, vol. 117, no. 2 (2006): 326-33.
Douwes J. "(1-->3)-Beta-D-glucans and respiratory health: a review of
the scientific evidence." Indoor Air, vol. 15, no. 3 (2005): 160-9.
Etzel R.A. "Indoor and outdoor air pollution: Tobacco smoke, moulds and
diseases in infants and children." International Journal of Hygiene and
Environmental Health, vol. 210, no. 5 (2007): 611-6.
Fisk, W.J., Lei-Gomez Q., and M.J. Mendell. "Meta-analyses of the
associations of respiratory health effects with dampness and mold in
homes." Indoor Air, vol. 17, no. 4 (2007): 284-96.
Gray, M. "Molds and Mycotoxins: Beyond Allergies and Asthma."
Alternative Therapies in Health and Medicine, vol. 13, no. 2 (2007):
S146-52.
Green B.J., Tovey E.R., Sercombe J.K., Blachere F.M., Beezhold D.H.,
and D. Schmechel. "Airborne fungal fragments and allergenicity."
Medical Mycology, vol. 44, no. S1 (2006): S245-55.
Habiba A. "Acute idiopathic pulmonary haemorrhage in infancy: Case
report and review of the literature." Journal of Paediatrics and Child
Health, vol. 41, no. 9-10 (2005): 532-3.
Hope, A.P., and R.A. Simon. "Excess dampness and mold growth in homes:
An evidence-based review of the aeroirritant effect and its potential
causes." Allergy and Asthma Proceedings, vol. 28, no. 3 (2007): 262-70.
Institute of Medicine, Clearing the Air: Asthma and Indoor Air
Exposures. Washington, D.C.: National Academy Press, 2000.
Institute of Medicine, Damp Indoor Spaces and Health. Washington, D.C.:
The National Academies Press, 2004.
Jarvis B.B., and J.D. Miller. "Mycotoxins as harmful indoor air
contaminants." Applied Microbiology and Biotechnology, vol. 66, no. 4
(2005): 367-72.
Khalili B., Montanaro M.T., and E.J. Bardana Jr. "Inhalational mold
toxicity: fact or fiction? a clinical review of 50 cases." Annals of
Allergy, Asthma & Immunology, vol. 95, no. 3 (2005): 239-46.
Lai K.-M. "Hazard Identification, Dose-Response and Environmental
Characteristics of Stachybotryotoxins and Other Health-Related Products
from Stachybotrys." Environmental Technology, vol. 27, no. 3 (2006):
329-35.
Laumbach R.J., and H.M. Kipen. "Bioaerosols and sick building syndrome:
particles, inflammation, and allergy." Current Opinion in Allergy and
Clinical Immunology, vol. 5, no. 2 (2005): 135-9.
Mazur L.J., and J. Kim; Committee on Environmental Health, American
Academy of Pediatrics. "Spectrum of Noninfectious Health Effects From
Molds." Pediatrics, vol. 118, no. 6 (2006): e1909-26.
Nuesslein T.G., Teig N., and C.H. Rieger. "Pulmonary haemosiderosis in
infants and children." Paediatric Respiratory Reviews, vol. 7, no. 1
(2006): 45-8.
Phipatanakul W. "Environmental Factors and Childhood Asthma." Pediatric
Annals, vol. 35, no. 9 (2006): 646-56.
Seltzer J.M., and M.J. Fedoruk. "Health Effects of Mold in Children."
Pediatric Clinics of North America, vol. 54, no. 2 (2007): 309-33, viii-
ix.
Susarla S.C., and L.L. Fan. "Diffuse alveolar hemorrhage syndromes in
children." Current Opinion in Pediatrics, vol. 19, no. 3 (2007): 314-
20.
Portnoy J.M., Kwak K., Dowling P., VanOsdol T., and C. Barnes. "Health
effects of indoor fungi." Annals of Allergy, Asthma & Immunology, vol.
94, no. 3 (2005): 313-20.
Richardson G., Eick S., and R. Jones. "How is the indoor environment
related to asthma?: literature review." Journal of Advanced Nursing,
vol. 52, no. 3 (2005): 328-39.
[End of section]
Appendix III: EPA, HHS, and HUD Ongoing Research Activities Addressing
Data Gaps Identified by the Institute of Medicine:
[Refer to PDF for image]
This figure contains a series of stacked horizontal bar graphs
depicting the following information:
Identify environmental factors that either lead to the development of
asthma or precipitate symptoms in subjects who already have asthma
using good measures of fungal exposure[A]:
EPA research activities reported: 9;
HHS research activities reported: 19;
HUD research activities reported: 4;
Total: 32.
Improve sampling and exposure assessment methods for mold and its
components (such as research that will help lead to standardization of
protocols for sample collection, transport, and analysis; or develop or
improve methods of personal airborne exposure measurement, DNA-based
technology, or assays for bioaerosols, etc.)[B]:
EPA research activities reported: 4;
HHS research activities reported: 23;
HUD research activities reported: 5;
Total: 32.
Determine the association of dampness problems with asthma development
and symptoms by researching the causative agents (e.g., molds, dust
mite allergens) and documenting the relationship between dampness and
allergen exposure[A]:
EPA research activities reported: 5;
HHS research activities reported: 16;
HUD research activities reported: 1;
Total: 22.
Identify fungal allergens or patterns of cross-reactivity among fungal
allergens:
EPA research activities reported: 11;
HHS research activities reported: 11;
HUD research activities reported: 0;
Total: 22.
Collect and analyze data on the interactions among multiple indoor
agents (such as mold, pesticides, and volatile organic compounds) and
environmental factors (such as humidity, temperature, and ventilation):
EPA research activities reported: 3;
HHS research activities reported: 15;
HUD research activities reported: 3;
Total: 21.
Develop information on the possible adverse health effects of dampness-
related emissions of mold spores from building materials and
furnishings:
EPA research activities reported: 2;
HHS research activities reported: 16;
HUD research activities reported: 0;
Total: 18.
Determine how to measure the effectiveness and health effects of mold
remediation efforts:
EPA research activities reported: 5;
HHS research activities reported: 9;
HUD research activities reported: 1;
Total: 15.
Better characterize the possible influence of the duration of moisture
damage on health:
EPA research activities reported: 4;
HHS research activities reported: 7;
HUD research activities reported: 2;
Total: 13.
Develop standardized metrics and protocols to assess the nature,
severity, and ex-tent of dampness and effectiveness of specific
measures for dampness reduction[B]:
EPA research activities reported: 4;
HHS research activities reported: 7;
HUD research activities reported: 2;
Total: 13.
Advance the understanding of specific bioaerosols in relation to asthma
by studying the epidemiology of building-related asthma in problem
buildings where there are excess chest complaints among occupants in
comparison to buildings where there are not complaints; or provide
exposure-response studies of many building environments and
populations:
EPA research activities reported: 3;
HHS research activities reported: 7;
HUD research activities reported: 0;
Total: 10.
Assess the effects of housing interventions (such as prevention or
remediation of moisture problems, etc.) on dampness and adverse health
effects, including the extent to which interventions are associated
with a decrease in the occurrence of adverse health effects, and
identify effective and efficient intervention strategies:
EPA research activities reported: 3;
HHS research activities reported: 5;
HUD research activities reported: 1;
Total: 9.
Better characterize the effectiveness of various means of protection
used during mold remediation activities:
EPA research activities reported: 1;
HHS research activities reported: 3;
HUD research activities reported: 1;
Total: 5.
Determine the effects of human exposure to Stachybotrys chartarum in
indoor environments:
EPA research activities reported: 2;
HHS research activities reported: 3;
HUD research activities reported: 0;
Total: 5.
Determine, for mycotoxins, the dose required to cause adverse health
effects in humans via inhalation and dermal exposure; techniques for
detecting and quantifying mycotoxins in tissues; or the effects of long-
term (chronic) exposures to mycotoxins via inhalation:
EPA research activities reported: 1;
HHS research activities reported: 3;
HUD research activities reported: 0;
Total: 4.
Research the relationship between mold and dampness and acute pulmonary
hemorrhage or hemosiderosis in infants:
EPA research activities reported: 0;
HHS research activities reported: 1;
HUD research activities reported: 0;
Total: 1.
Source: GAO analysis of EPA, HHS, and HUD survey data.
Notes: These data are for the 65 federal mold research activities
ongoing as of October 1, 2007. Federal officials reported which of the
data gaps identified by the 2000 and 2004 Institute of Medicine reports
their research activities are addressing. Each activity can address
multiple data gaps.
In fact, many of the activities are reported to address three or more
gaps. Summaries of the 65 research activities conducted or sponsored by
EPA, HHS, and HUD are provided in a supplement to this report (GAO-08-
984SP).
Agency officials reported that eight federal mold research activities
currently being conducted do not directly address any of the data gaps
identified by the 2000 and 2004 Institute of Medicine reports. Some of
these studies were directed at medical treatments and others were
focused on other potential causes of asthma. For example, one study is
evaluating whether chronic rhinosinusitis is induced by an abnormal
immune response to mold and therefore whether an anti-fungal agent will
be an effective treatment of the disease. Another study is developing
and validating DNA-based methods for identification and fingerprinting
medically important fungi. Several of these research activities focused
on asthma. For example, two studies, one of children in El Paso and
another of children in Detroit, are primarily focused on the role of
residential proximity to roadways in the development of childhood
asthma but also collected data on indoor exposures, including home
dampness and the presence of visible molds. Another study being
conducted is designed to test the hypothesis that asthma control in low
income, urban adolescents and young adults can be improved with the
addition of exhaled nitric oxide as a marker for treatment guidance to
conventional asthma management guidelines; a secondary purpose of this
study is to examine the role of allergy to molds in influencing the
effectiveness of the asthma management plan.
[A] Asthma data gaps identified by the 2000 and 2004 Institute of
Medicine reports.
[B] Measurement methods data gaps identified by the 2000 and 2004
Institute of Medicine reports.
[End of figure]
[End of section]
Appendix IV Federal Agency Program Offices Contacted Regarding Their
Mold-Related Research:
[End of section]
We obtained information on federal research related to the health
effects of exposure to indoor mold from three key agencies--EPA, HHS,
and HUD. We obtained and analyzed information and interviewed program
managers and other officials responsible for research at these
agencies. Following are the offices, centers, and other program units
we surveyed regarding their mold-related research.[Footnote 62]
Environmental Protection Agency:
Office of Air and Radiation:
* Office of Radiation and Indoor Air:
- Indoor Environments Division:
- Radiation and Indoor Environments National Laboratory:
- National Air and Radiation Environmental Laboratory:
Office of Research and Development:
* Office of the Assistant Administrator:
* National Health and Environmental Effects Research Laboratory:
- Experimental Toxicology Division:
- Human Studies Division:
* National Exposure Research Laboratory:
- Microbiological and Chemical Exposure Assessment Research Division:
* National Risk Management Research Laboratory:
- Air Pollution Prevention and Control Division:
* National Homeland Security Research Center:
* National Center for Environmental Research:
* National Center for Environmental Assessment:
Office of Prevention, Pesticides, and Toxic Substances:
* Office of Pesticide Programs:
- Antimicrobials Division:
- Field and External Affairs Division:
- Special Review and Reregistration:
- Office of Pollution Prevention and Toxics:
- Environmental Assistance Division:
Office of the Administrator:
*Office of Children's Health Protection and Environmental Education:
- Child and Aging Health Protection Division:
Office of Solid Waste and Emergency Response:
Department of Health and Human Services:
Centers for Disease Control and Prevention:
Office of Chief Science Officer:
Coordinating Office for Terrorism Preparedness and Emergency Response:
Coordinating Center for Health Information and Service:
* National Center for Health Marketing:
Coordinating Center for Infectious Diseases:
* National Center for Immunization and Respiratory Diseases:
- Influenza Coordination Unit:
Coordinating Center for Environmental Health and Injury Prevention:
* National Center for Environmental Health:
- Division of Environmental Hazards and Health Effects; Air Pollution
and Respiratory Health Branch:
- Division of Emergency and Environmental Health Services: Lead
Poisoning Prevention Branch:
* Agency for Toxic Substances and Disease Registry:
- Division of Health Assessment and Consultation: Cooperative Agreement
and Program Evaluation Branch:
* Division of Health Studies:
National Institute for Occupational Safety and Health:
* Office of the Director:
- Office of the Associate Director for Science:
- Office of Extramural Coordination and Special Projects:
* Health Effects Laboratory Division:
- Pathology and Physiological Research Branch:
- Allergy and Clinical Immunology Branch:
* Division of Surveillance, Hazard Evaluations, and Field Studies:
- Hazard Evaluations and Technical Assistance Branch:
- Industrywide Studies Branch:
* Division of Respiratory Disease Studies:
- Field Studies Branch:
- Laboratory Research Branch:
National Center for Zoonotic, Vector-Borne, and Enteric Diseases:
* Division of Foodborne, Bacterial and Mycotic Diseases:
- Mycotic Diseases Branch:
National Institutes of Health:
National Human Genome Research Institute:
* Office of Population Genomics:
National Institute of Allergy and Infectious Diseases:
* Division of Clinical Research:
* Division of Microbiology and Infectious Diseases:
* Division of Allergy, Immunology, and Transplantation:
- Office of Program Planning, Operations and Scientific Information:
- Asthma, Allergy and Inflammation Branch:
National Heart, Lung, and Blood Institute:
* Division of Lung Diseases:
* Division for the Application of Research Discoveries:
National Institute of Environmental Health Sciences:
* Office of the Director:
* Division of Extramural Research and Training:
* Division of Intramural Research:
- National Toxicology Program:
- Environmental Diseases and Medicine Program:
- Clinical Research Program:
* Office of Translational Research:
Office of the Assistant Secretary for Health:
Office of Public Health and Science:
* Office of the Surgeon General:
* Commissioned Corps of the U.S. Public Health Service:
- Chief Professional Officer:
Medical:
Environmental Health:
Health Services:
Scientist:
Office of the Assistant Secretary for Administration and Management:
Program Support Center:
* Federal Occupational Health:
- Environmental Health Services:
Department of Housing and Urban Development:
Office of the Assistant Secretary for Policy Development and Research:
* Office of Deputy Assistant Secretary for Research, Evaluation, and
Monitoring:
- Affordable Housing Research and Technology Division:
Office of Healthy Homes and Lead Hazard Control:
* Policy and Standards Division:
Office of Public and Indian Housing:
* Office of Public Housing Investments:
- Office of Capital Improvements:
* Office of Native American Programs:
* Real Estate Assessment Center:
- Physical Inspection Quality Assurance Division:
Office of Housing:
* Office for Regulatory Affairs and Manufactured Housing:
- Office of Manufactured Housing Programs:
[End of section]
Appendix V: Selected Publicly Available Federal Guidance Related to
Mold:
Consumer Product Safety Commission and the American Lung Association,
Biological Pollutants in Your Home (Bethesda, Md., 1990). [hyperlink,
http://www.cpsc.gov/cpscpub/pubs/425.html] (accessed May 8, 2008).
Consumer Product Safety Commission and the Environmental Protection
Agency, The Inside Story: A Guide to Indoor Air Quality (Washington,
D.C., 1995). [hyperlink, http://www.epa.gov/iaq/pubs/insidest.html]
(accessed May 8, 2008).
Environmental Protection Agency, Addressing Indoor Environmental
Concerns During Remodeling (Washington, D.C., 2007). [hyperlink,
http://www.epa.gov/iaq/homes/hip-concerns.html] (accessed May 9, 2008).
Environmental Protection Agency, Age Healthier Breathe Easier
(Washington, D.C., 2004). [hyperlink,
http://www.epa.gov/aging/resources/factsheets/ahbe_english_2004_0330.pdd
] (accessed May 9, 2008).
Environmental Protection Agency, A Brief Guide to Mold, Moisture, and
Your Home (Washington, D.C., 2002). [hyperlink,
http://www.epa.gov/mold/moldguide.html] (accessed May 9, 2008).
Environmental Protection Agency, Cleaning Up After a Flood: Addressing
Mold Problems (Washington, D.C., 2005). [hyperlink,
http://www.epa.gov/katrina/outreach/mold.pdf] (accessed May 9, 2008).
Environmental Protection Agency, Controlling Moisture (Washington,
D.C., 2007). [hyperlink, http://www.epa.gov/iaq/homes/hip-
moisture.html] (accessed May 9, 2008).
Environmental Protection Agency, Live, Learn, Play--Tune in to Your
Health and Environment (Washington, D.C., 2004). [hyperlink,
http://yosemite.epa.gov/ochp/ochpweb.nsf/content/dirt.htm] (accessed
May 9, 2008).
Environmental Protection Agency, Flood Cleanup--Avoiding Indoor Air
Quality Problems (Fact Sheet) (Washington, D.C., 2003). [hyperlink,
http://www.epa.gov/mold/pdfs/floods.pdf] (accessed May 9, 2008).
Environmental Protection Agency, Flood Cleanup and the Air in your Home
(Washington, D.C., 2006). [hyperlink,
http://www.epa.gov/mold/flood/index.html] (accessed May 9, 2008).
Environmental Protection Agency, What are ten things I need to know
about mold? (Washington, D.C., 2008). [hyperlink,
http://iaq.custhelp.com/cgi-bin/iaq.cfg/php/enduser/std_alp.php]
(accessed May 9, 2008).
Environmental Protection Agency, What You Can Do to Protect Children
from Environmental Risks (Washington, D.C., 2002). [hyperlink,
http://yosemite.epa.gov/ochp/ochpweb.nsf/content/tips.htm] (accessed
May 9, 2008).
Environmental Protection Agency; Department of Agriculture, Cooperative
State Research, Education, and Extension Service; Department of Housing
and Urban Development; Montana State University Extension Service; and
Alabama Cooperative Extension System at Auburn University, Healthy
Indoor Air for America's Homes (Bozeman, Mont., 2007). [hyperlink,
http://www.montana.edu/wwwcxair/] (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Molds in the Environment (Atlanta, 2005). [hyperlink,
http://www.cdc.gov/mold/faqs.htm] (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Facts About Mold And Dampness (Atlanta, 2005).
[hyperlink, http://www.cdc.gov/mold/dampness_facts.htm\ (accessed May
9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Mold Questions and Answers: Questions and Answers on
Stachybotrys chartarum and other molds (Atlanta, 2004). [hyperlink,
http://www.cdc.gov/mold/stachy.htm] (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Protect Yourself from Mold (Atlanta, 2006). [hyperlink,
http://www.bt.cdc.gov/disasters/mold/protect.asp] (accessed May 9,
2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Mold Prevention Strategies and Possible Health Effects
in the Aftermath of Hurricanes and Major Floods (Atlanta, 2006).
[hyperlink, http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm]
(accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control
and Prevention, Population-Specific Recommendations for Protection From
Exposure to Mold in Buildings Flooded After Hurricanes Katrina and
Rita, by Specific Activity and Risk Factor (Atlanta, 2005). [hyperlink,
http://www.bt.cdc.gov/disasters/mold/report/pdf/2005_moldtable5.pdf]
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management Agency,
Dealing with Mold and Mildew in Your Flood Damaged Home (Washington,
D.C., 2005). [hyperlink,
http://www.fema.gov/pdf/rebuild/recover/fema_mold_brochure_english.pdf]
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management Agency,
Got Mold? Clean, Disinfect and Dry (Wichita, Kans., 2007). [hyperlink,
http://www.fema.gov/news/newsrelease.fema?id=37791] (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management Agency,
Mold Can Be A Danger When Evacuees Return Home (Baton Rouge, La.,
2005). [hyperlink, http://www.fema.gov/news/newsrelease.fema?id=19302]
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management Agency,
Mold--A Growing Threat (Andover, Mass., 2006). [hyperlink,
http://www.fema.gov/news/newsrelease.fema?id=26898] (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management Agency,
Mold: A Health Hazard (Montgomery, Ala., 2005). [hyperlink,
http://www.fema.gov/news/newsrelease.fema?id=20379] (accessed May 9,
2008).
Department of Homeland Security, Federal Emergency Management Agency,
Mold: Potential Threat to Health and Homes (Austin, Tex., 2005).
[hyperlink, http://www.fema.gov/news/newsrelease.fema?id=19767]
(accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management Agency,
Prompt Cleanup Of Mold And Mildew Is Essential (Newington, N.H., 2006).
[hyperlink, http://www.fema.gov/news/newsrelease.fema?id=27186]
(accessed July 1, 2008).
Department of Homeland Security, Federal Emergency Management Agency,
Water-Damaged Homes May Harbor Mold Problem (Washington, D.C., 2007).
[hyperlink, http://www.fema.gov/news/newsrelease.fema?id=36536]
(accessed May 9, 2008).
Department of Housing and Urban Development, About Mold and Moisture
(Washington, D.C., 2007). [hyperlink,
http://www.hud.gov/offices/lead/healthyhomes/mold.cfm] (accessed May 9,
2008).
Department of Housing and Urban Development, Healthy Homes Program
(Washington, D.C., 2003). [hyperlink,
http://www.hud.gov/offices/lead/library/hhi/HH_Brochure_Revised.pdf]
(accessed May 9, 2008).
Department of Housing and Urban Development, Mold and Moisture
Prevention: A Guide for Residents in Indian Country (Washington, D.C.,
2004). [hyperlink,
http://www.hud.gov/offices/pih/ih/codetalk/docs/moldprevention.pdf]
(accessed May 9, 2008).
[End of section]
Department of Housing and Urban Development, Mold (Washington, D.C.,
2005). [hyperlink,
http://www.hud.gov/offices/lead/library/hhi/Mold.pdf] (accessed May 9,
2008).
Department of Housing and Urban Development; Department of Agriculture,
Cooperative State Research, Education, and Extension Service; and
University of Wisconsin Healthy Homes Partnership, Help Yourself to a
Healthy Home (Washington, D.C., 2002). [hyperlink,
http://www.hud.gov/offices/lead/library/hhi/HYHH_Booklet.pdf] (accessed
May 9, 2008).
[End of section]
Appendix VI: GAO Contact and Staff Acknowledgments:
GAO Contact:
John B. Stephenson, (202) 512-3841 or stephensonj@gao.gov:
Staff Acknowledgments:
In addition to the contact named above, Christine Fishkin, Assistant
Director; Krista Breen Anderson; Nancy Crothers; Benjamin Howe; Richard
P. Johnson; Nico Sloss; and Ruth Solomon made key contributions to this
report. Linda Choy; Michael Derr; Alice Feldesman; Terrance Horner;
Armetha Liles; Luann Moy; and Anne Rhodes-Kline also made important
contributions.
[End of section]
Footnotes:
[1] In this report, we use the term "mold" to refer to the large number
of species of fungi.
[2] National Institute of Environmental Health Sciences, "A Spreading
Concern: Inhalational Health Effects of Mold," Environmental Health
Perspectives (June 2007).
[3] Department of Health and Human Services, Centers for Disease
Control and Prevention, Mold Prevention Strategies and Possible Health
Effects in the Aftermath of Hurricanes and Major Floods (Atlanta,
2006).
[4] The National Academies comprises four organizations: the National
Academy of Sciences, the National Academy of Engineering, the Institute
of Medicine, and the National Research Council.
[5] Institute of Medicine, Damp Indoor Spaces and Health (Washington,
D.C.: The National Academies Press, 2004).
[6] Institute of Medicine, Clearing the Air: Asthma and Indoor Air
Exposures (Washington, D.C.: National Academy Press, 2000).
[7] GAO, Hurricane Katrina: EPA's Current and Future Environmental
Protection Efforts Could Be Enhanced by Addressing Issues and
Challenges Faced on the Gulf Coast, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO-07-651] (Washington, D.C.: June 25, 2007).
[8] Pub. L. No. 99-499, Title IV, §§ 401 to 405 (1986).
[9] GAO, Indoor Air Pollution: Federal Efforts Are Not Effectively
Addressing a Growing Problem, [hyperlink, http://www.gao.gov/cgi-
bin/getrpt?GAO/RCED-92-8] (Washington, D.C.: Oct. 15, 1991).
[10] According to CDC officials, it is not yet possible to establish
mold exposure limits for indoor air.
[11] Information on state laws comes from data assembled by the
National Association of Mutual Insurance Companies (NAMIC) at
[hyperlink, http://www.namic.org].
[12] L.J. Mazur, J. Kim, and Committee on Environmental Health,
American Academy of Pediatrics, "Spectrum of Noninfectious Health
Effects From Molds," Pediatrics, vol. 118, no. 6 (2006).
[13] Two of the reviews focused primarily on clinical cases encountered
by the authors. For a list of the studies we reviewed, see appendix II.
[14] The authors of this report acknowledged that, because of the
presence of other potential disease-causing agents indoors, it is not
possible to definitively attribute a causal relationship to any one
specific agent in indoor environments.
[15] A meta-analysis uses statistical methods to combine data from
different but comparable research studies, in order to provide a
quantitative summary estimate on the size and variability of an
association.
[16] W.J. Fisk, Q. Lei-Gomez, and M.J. Mendell, "Meta-analyses of the
associations of respiratory health effects with dampness and mold in
homes," Indoor Air, vol. 17, no. 4 (2007).
[17] J.M. Seltzer and M.J. Fedoruk, "Health Effects of Mold in
Children," Pediatric Clinics of North America, vol. 54, no. 2 (2007).
[18] A. Habiba, "Acute idiopathic pulmonary haemorrhage in infancy:
Case report and review of the literature," Journal of Paediatrics and
Child Health, vol. 41, no. 9-10 (2005); and S.C. Susarla and L.L. Fan,
"Diffuse alveolar hemorrhage syndromes in children," Current Opinion in
Pediatrics, vol. 19, no. 3 (2007).
[19] T.G. Nuesslein, N. Teig, and C.H. Rieger, "Pulmonary
haemosiderosis in infants and children," Paediatric Respiratory
Reviews, vol. 7, no. 1 (2006).
[20] R.A. Etzel, "Indoor and outdoor air pollution: Tobacco smoke,
moulds and diseases in infants and children," International Journal of
Hygiene and Environmental Health, vol. 210, no. 5 (2007).
[21] In addition to the 2006 American Academy of Pediatrics review and
Seltzer and Fedoruk (2007), A.T. Borchers, C. Chang, C.L. Keen, and
M.E. Gershwin, "Airborne Environmental Injuries and Human Health,"
Clinical Reviews in Allergy & Immunology, vol. 31, no. 1 (2006); K.-M.
Lai, "Hazard Identification, Dose-Response and Environmental
Characteristics of Stachybotryotoxins and Other Health-Related Products
from Stachybotrys," Environmental Technology, vol. 27, no. 3 (2006);
and J.M. Portnoy, K. Kwak, P. Dowling, T. VanOsdol, and C. Barnes,
"Health effects of indoor fungi," Annals of Allergy, Asthma &
Immunology, vol. 94, no. 3 (2005).
[22] B.B. Jarvis and J.D. Miller, "Mycotoxins as harmful indoor air
contaminants," Applied Microbiology and Biotechnology, vol. 66, no. 4
(2005).
[23] R.K. Bush, J.M. Portnoy, A. Saxon, A.I. Terr, and R.A. Wood, "The
medical effects of mold exposure," The Journal of Allergy and Clinical
Immunology, vol. 117, no. 2 (2006).
[24] Although our review focuses on the research needs directly related
to indoor mold and human health, the 2000 and 2004 Institute of
Medicine reports identified a variety of other research needs related
to dampness, mold, and buildings.
[25] Other methods to protect building occupants and workers may
involve containment efforts to control the dispersal of mold through
the building during remediation, which can disturb building materials
and release mold (particularly its spores) into the air.
[26] Clearing the Air and Damp Indoor Spaces and Health.
[27] We aggregated the research needs on the health effects of exposure
to indoor mold that were identified in the 2000 and 2004 Institute of
Medicine reports into 15 groups of related needs.
[28] These studies are titled "The Effect of Gestational Exposure to
Mold on Allergy Induction in a Mouse Model," "Study of Putative
Asthmagenic Molds," and "Development of an Animal Model to Evaluate the
Contribution of the Fungal Product, -glucan, on the Pulmonary
Inflammatory Potential of Indoor Dust Samples."
[29] These studies are titled "Health Effects of Exposure to Water-
Damaged New Orleans Homes Six Months After Hurricanes Katrina and Rita"
and "Building-Related Asthma Research in Maine Public Schools."
[30] This research activity is titled "The Development of Monoclonal
Antibody-Based Immunodiagnostics for Fungal Hemolysins as Potential
Biomarkers of Fungal Exposure."
[31] These studies are titled "Toxicology Studies of Mold Exposures,"
"Fluorescent Multiplex Array for Indoor Allergens (which is using
enzyme immunoassay and multiplex array technology)," and "Aptamer-Based
Microarray for the Detection of Environmental Allergens."
[32] While HHS did not classify this ongoing research, "Study on
Identification and Typing (Fingerprinting) Medically Important Fungal
Organisms Using DNA," as meeting the data gaps on sampling or
measurement methods identified by the Institute of Medicine reports, we
believe that the information from this research activity has the
potential to address important measurement gaps.
[33] These research activities are titled "Study on Asthma and
Environmental Factors, Which Included an Application of the ERMI Index"
and "Determining the National Distribution of Selected Contaminants
(Including Mold) in the Residential Environment (i.e., the American
Healthy Homes Survey)." The ERMI scale can describe the mold burden in
any home on the basis of its relative position compared with the entire
U.S. housing stock.
[34] One of the nine research activities is addressing two of the three
data gaps to some extent. To avoid double counting, this research
activity is counted once.
[35] This study is titled "Study on Biomarkers for Exposure to
Stachybotrys Chartarum."
[36] According to a CDC official, from January 2004 to June 2005, the
agency undertook a "chart review" of pulmonary hemorrhage designed to
determine if existing computerized information sources (such as
hospital discharge and vital statistics data) or other information
could be used for national surveillance of acute pulmonary hemorrhage
in infants. After evaluating hospital records in six cities, CDC's
preliminary conclusions are that national data sets are not reliable
for this purpose and that local data sources should be used instead.
[37] These studies are titled "Head-off Environmental Asthma in
Louisiana," "Relative Potency of Mold Extraction in a Mouse Model,"
"Fluorescent Multiplex Array for Indoor Allergens," "Study on
Biomarkers for Exposure to Stachybotrys Chartarum," and "Urban Moisture
and Mold Program-Continuation Project."
[38] These activities are titled "Toxicology Studies of Mold Exposures"
and "Allosteric DNAzyme Sensors for Practical Detection of Mycotoxins."
[39] This study is titled "The Role of Neutrophils in Hypersensitivity
Pneumonitis."
[40] This study is titled "Mechanistic Indicators of Childhood Asthma
(MICA) Study."
[41] HUD did not report any completed mold-related research activities
during this time frame.
[42] EPA, Program Needs for Indoor Environments Research, EPA 402-B-05-
001 (March 2005).
[43] These are the National Institute of Environmental Health Sciences;
the National Heart, Lung, and Blood Institute; and the National
Institute of Allergy and Infectious Diseases.
[44] One of the 29 research activities was funded partly by an
unsolicited grant and partly by a solicited cooperative agreement. We
considered this activity as both unsolicited and solicited.
[45] An NIH official said that after the peer-review process is
completed, proposals are given a merit score, which is based on factors
such as the qualifications of the researcher and the level of
innovation and significance of the research. Funding is then allocated
to research activities in priority order based on this ranking.
[46] GAO, Results-Oriented Government: Practices That Can Help Enhance
and Sustain Collaboration among Federal Agencies, [hyperlink,
http://www.gao.gov/cgi-bin/getrpt?GAO-06-15] (Washington, D.C.: Oct.
21, 2005).
[47] EPA, Report to Congress on Indoor Air Quality: Volume I: Federal
Programs Addressing Indoor Air Quality, EPA/400/1-89/001B (August
1989).
[48] All the HHS guidance documents we reviewed were issued by CDC.
[49] The six adverse health effects identified by the Institute of
Medicine are the exacerbation of asthma symptoms, upper respiratory
tract symptoms, cough, wheeze, hypersensitivity pneumonitis, and
opportunistic infections and fungal colonization in immune-compromised
individuals.
[50] Department of Health and Human Services, Centers for Disease
Control and Prevention, Mold Prevention Strategies and Possible Health
Effects in the Aftermath of Hurricanes and Major Floods (Atlanta,
2006).
[51] Department of Homeland Security, Federal Emergency Management
Agency, Dealing with Mold and Mildew in Your Flood Damaged Home
(Washington, D.C., 2005). Department of Health and Human Services,
Centers for Disease Control and Prevention, Mold Questions and Answers:
Questions and Answers on Stachybotrys chartarum and other molds
(Atlanta, 2004); Facts About Mold And Dampness (Atlanta, 2005); and
Molds in the Environment (Atlanta, 2005).
[52] EPA, Mold Remediation in Schools and Commercial Buildings
(Washington, D.C., June 2001).
[53] Guidance documents typically referred readers to this report if
mold removal exceeds 10 square feet, although it also addresses mold
cleanups of less than 10 square feet.
[54] As discussed earlier in this report, however, litigants attempting
to show that exposure to indoor mold has resulted in adverse health
effects generally need to demonstrate to courts that a specific species
of mold caused a specific adverse health outcome.
[55] EPA, Mold Remediation.
[56] The smallest areas addressed by guidance documents we reviewed
vary from up to 10 square feet to up to 100 square feet.
[57] Department of Health and Human Services, Centers for Disease
Control and Prevention, Mold Prevention Strategies and Possible Health
Effects in the Aftermath of Hurricanes and Major Floods (Atlanta, 2006)
and Population-Specific Recommendations for Protection From Exposure to
Mold in Buildings Flooded After Hurricanes Katrina and Rita, by
Specific Activity and Risk Factor (Atlanta, 2005).
[58] We use the term guidance to describe non-binding communications
agencies issue to the public for educational purposes.
[59] We considered guidance to be issued by an agency if the agency is
identified as its author or the guidance displays the agency's logo.
Guidance documents can be sponsored by multiple federal agencies, and
some of the guidance we reviewed was also sponsored by agencies other
than those mentioned above, such as the Department of Agriculture.
[60] Nonprobability samples cannot be used to generalize or make
inferences about a population. In this instance, we cannot generalize
the results of our review of federal guidance to all federal guidance
to the general public on the health effects of indoor mold issued by
the Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD.
[61] For example, we examined guidance from the Occupational Safety and
Hazard Administration of the Department of Labor, but excluded it from
our analysis because the mold-related information in this guidance was
tailored to an occupational and professional context only.
[62] We contacted at least one person in each program office. Officials
in some of the program offices listed in this appendix responded that
they were not conducting or sponsoring any mold research. In addition,
some of the officials we contacted involved with indoor mold research
had left their agencies; their offices are not represented in this
appendix.
[End of section]
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