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Mold: A Sensible Response

Susan Walters Schmid, BA, MA, PhD (candidate)

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Mold is everywhere! Mold from outdoors may be brought inside on clothing, pets, or other surfaces, and it may be found growing indoors when conditions are favorable. When people sensitive to mold come in contact with it, whether the mold is dead or alive, they may experience a variety of adverse health effects. These can be especially dangerous for immuno-compromised persons or those with chronic lung disease (Storey, 2004).

Clearly mold is potentially of concern to everyone, including healthcare workers in many occupational settings. Whether you work in a large or small institutional setting, manage your own practice, or are engaged in home visits, you may encounter the evidence and effects of mold and need to take action for yourself or your clients.

INVASIVE MOLD

Wherever there is moisture indoors in a place it doesn't belong, mold can grow. The moisture may have an obvious source, such as a flood or other inundation, but it can also be coming from a leaking pipe or sprinkler system, improperly draining gutters, standing water, even just a little condensation from excess humidity. These and other water problems and the consequent mold growth can be a problem in homes and in institutional settings of all kinds—daycare centers, schools, hospitals, clinics, retail outlets and office buildings.

Even though mold has been in the environment for thousands of years, it seems to have become more of a problem and a more public problem in recent years. Researchers cite a number of possible explanations for this, including a far larger population of immuno-compromised or immuno-stressed persons, a large increase in urban dwellers and those living in wetter areas, and it may even be linked to changes in building practices, such as requirements that have led to more airtight construction methods (Weinhold, 2007).

Much research remains to be done and many research projects are ongoing, including a project aimed at creating a "moldiness index." As with many high profile topics, there is often confusion, contradictory information, and media attention. Healthcare workers—especially those who may find themselves making home visits and/or working one-on-one with clients—should be aware of the basics of about molds, how they proliferate, likely symptoms in those with mold sensitivity, and remediation information. This will allow healthcare workers to recognize those possibly in need of treatment for mold sensitivity responses, offer sensible advice, and point clients toward reliable information and resources.

Mold growing indoors presents two equally important problems:

• Getting rid of the mold
• Removing the moisture source

In addition, the mold may have caused or be causing structural and/or cosmetic damage to buildings or other surfaces and adverse health effects in people exposed to the mold, whether through inhalation or direct contact.

While research is ongoing, especially on the human health effects of mold contact and the controversies surrounding those effects, most authorities agree that if you find mold growing where it should not be, you need to remove it and you should follow certain specific protocols for doing so.

RECOGNIZING MOLD

Molds (also called fungi, mildew) are members of the fungi kingdom—neither animals nor plants. They occur naturally, indoors and out, and serve an important environmental role in the decomposition of organic materials. There are more than 100,000 known species of mold, with about 1,000 found in the United States (OSHA, 2003).

Molds reproduce by means of microscopic spores (2–100 microns, or μm, in diameter). These tiny spores can float through the air, and may travel great distances before settling on a surface. While mold spores are everywhere, the number in a given environment fluctuates all the time, and even when spores settle they will not grow if no moisture is present.

Once spores start growing, they digest the organic surface on which they have settled and can cause significant cosmetic and structural damage to building materials, furnishings, clothing, books, and other materials if the growth remains unchecked (EPA, 2007; OSHA, 2003).

Molds occur in a variety of colors, including green, white, and black; and mold often gives off a characteristic musty or acrid smell. Certain compounds given off by molds known as microbial volatile organic compounds (mVOCs) have strong smells and can be responsible for this odor. Molds may produce allergens (substances that can cause allergic reactions), irritants, or mycotoxins. Molds that produce mycotoxins are often referred to as toxigenic fungi. Sometimes media reports will refer to "black mold" or "toxic mold"; however, neither are specific kinds of mold, they are simply media terms (EPA, 2007; Weinhold, 2007).

The single most important factor in mold growth is a moisture source. Consequently, if you can control the source(s) of moisture you can usually control the growth of mold.

In addition to moisture, molds require oxygen and food for growth. Any organic substance may serve as food, including wood, paper, cloth, plant materials, even soil. In buildings this means gypsum, wallboard, floors, and materials found in crawl spaces are all at risk for mold growth if moisture is present. Temperature is not usually a critical factor because molds will grow at most temperatures—some prefer cool conditions, while others like warm ones. More than one type of mold may be found growing in the same location even if the conditions favor a particular type (EPA, 2007).

Mold is commonly found in window areas, bathrooms, laundry rooms, basements, and roof areas. In schools and commercial buildings, other areas may include the surroundings of drinking fountains and sinks, in and around heating, ventilation, and air conditioning (HVAC) components, and around sprinkler system components. These areas all share a susceptibility to cold spots, excess humidity, leaks, or flooding (inundation) (EPA, 2007).

There are no quantifying tests or standards for identifying mold, and the CDC counsels that residential testing is almost always unnecessary (CDC, 2005). The critical point is that if you see it and/or smell it, it is mold and it needs to be removed. At the same time, it is important to remember that mold may be growing in areas where it cannot be seen or smelled, so be aware of the signs of possible mold growth, and after a flood or other inundation, follow proper protocols for remediation, even if you see and smell nothing.

Even in commercial/institutional settings, the first priority will usually be to get rid of the mold, then to repair damage and take steps to prevent further mold growth. Testing can be expensive, and the results may not be definitive because there are no federal recommendations or standards, and understanding of the links between mold and adverse health effects is incomplete (OSHA, 2003).

Individuals responsible for public spaces and/or large areas should consult OSHA guidelines along with their institutional policies and local health agency recommendations regarding testing and remediation. In institutional settings there may be reasons to pursue certain kinds of sampling.

For example, sampling might be done in order to evaluate the efficacy of a cleanup process. Samples are taken to compare the quantity of a particular mold inside a building with that outside the building, and the same sampling is repeated after indoor cleanup procedures have been completed.

Samples may be taken to test a theory such as whether more mold is present when an HVAC system is running than when it is shut off. In the end, most authorities agree that if money is limited it is always better spent on cleanup measures than on investigation. Consult with an industrial hygienist or a similar experienced environmental health and safety professional if you have questions (OSHA, 2003).

MOLD AND HEALTH

Even twenty-five years ago, inhaled mold was thought to be mainly a nuisance, but growing medical and scientific evidence suggests that not only is the problem much more widespread than previously thought but it may also be a much more serious threat for some individuals (Weinhold, 2007). In a 2006 report the 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."

But there are still many gaps in specific knowledge about who is most affected and to what degree, and much research is still in progress (Weinhold, 2007; Brandt, 2006). Healthcare workers need to keep abreast of new developments through the various information sources listed at the end of this course as well as their state and local health departments.

Who Is Affected by Mold Exposure?

Molds produce allergens and irritants. People exposed, through inhalation or skin contact, to mold—dead or alive—may report allergic reactions, asthma attacks, or other irritant effects. Not everyone reacts to molds the same way, but allergic reactions are common and may occur immediately on contact or after some delay (EPA, 2007; RIDH, n.d.). Populations generally more sensitive to molds include:

• Infants and children
• Older adults
• People with weak immune systems, such as those who have HIV infection, cancer, or who are in chemotherapy
• People with chronic respiratory illnesses or respiratory conditions such as allergies and asthma (RIDH, n.d.)

For those who are susceptible to asthma, mold exposure may trigger asthma attacks. Nonsensitive individuals may find that repeated, or even a single, exposure to mold, mold spores, or mold fragments causes them to become sensitized, and repeated exposure has the potential to increase sensitivity. Inhaling mold can also cause an uncommon disease called hypersensitivity pneumonitis, and in persons with weakened immune systems, mold exposure may cause opportunistic infections (EPA, 2007).

What Are Their Symptoms?

Allergic reactions and irritant effects may include:

• Headache
• Sneezing
• Coughing
• Wheezing
• Runny nose
• Red or watery eyes
• Skin rash (dermatitis)
• Itching
• Fatigue (EPA, 2007; RIDH)

If an office or commercial building has a mold problem, workers may report symptoms such as those listed above as well as increased asthma attacks or other symptoms. Situations such as dampness that encourage mold growth may foster bacterial and other problems, with adverse health affects. Thus, it is important to consider other possible contributors to adverse health responses, and to work with professionals if necessary to evaluate the situation.

Mycotoxins

In addition to allergens, some molds produce mycotoxins, which are potentially toxic, and, unlike allergens, a sufficient concentration of a mycotoxin can "elicit a response from anyone" with whom they come in contact" (Storey, 2004). According to the CDC, there are about 500 fungal species that are "thought to be harmful" to humans.

More than 200 mycotoxins have been identified and, while the effects of some are well known (eg,trichophyton, which causes athlete's foot), others have not yet been identified, and for many, little is known about them or their potential health affects. Because it is not possible to know from looking at a mold if it is producing mycotoxins and because exposure can come from inhalation, ingestion, and/or skin contact, prudence is important at all times when dealing with mold (EPA, 2007; Weinhold, 2007; RIDH, n.d.).

GETTING RID OF MOLD

While getting rid of mold (remediation) is generally the first priority regardless of location, the best way to accomplish the task depends first on the size of the area affected and then on the types of contaminated materials. Other considerations may involve occupants of the area, known or suspected presence of a toxigenic mold, the potential of mold to become airborne, and the possibility of extensive hidden mold (EPA, 2007).

The Occupational Safety and Health Administration (OSHA) divides remediation areas into four levels (I–IV) based on square footage affected, ranging from 10 square feet or less to greater than 100 square feet. The EPA uses a similar categorization of small, medium, and large, also based on size of area affected. In both cases the smallest unit—Level I, or Small—involves 10 square feet or less and would be the common area homeowners might encounter and be able to clean for themselves. See Table 1 for details on area and affected materials as they correspond with cleanup methods, personal protective equipment (PPE), and containment requirements.

TABLE 1

GUIDELINES FOR REMEDIATING BUILDING MATERIALS WITH MOLD GROWTH CAUSED BY CLEAN WATER

Material or Furnishing Affected	Cleanup Methods†	Personal Protective Equipment*	Containment**
SMALL - total surface area affected less than 10 square feet (ft2)
Books and papers	3	Minimum N-95 respirator, gloves, and goggles	None required
Carpet and backing	1, 3
Concrete or cinder block	1, 3
Hard surface, porous flooring (linoleum, ceramic tile, vinyl)	1, 2, 3
Non-porous, hard surfaces (plastics, metals)	1, 2, 3
Upholstered furniture & drapes	1, 3
Wallboard (drywall and gypsum board)	3
Wood surfaces	1, 2, 3
MEDIUM - total surface area affected between 10 and 100 (ft2)
Books and papers	3	Limited or Full Use professional judgment, consider potential for remediator exposure and size of contaminated area	Limited Use professional judgment, consider potential for remediator/occupant exposure and size of contaminated area
Carpet and backing	1,3,4
Concrete or cinder block	1,3
Hard surface, porous flooring (linoleum, ceramic tile, vinyl)	1,2,3
Non-porous, hard surfaces (plastics, metals)	1,2,3
Upholstered furniture & drapes	1,3,4
Wallboard (drywall and gypsum board)	3,4
Wood surfaces	1,2,3
LARGE - total surface area affected greater than 100 (ft2) or potential for increased occupant or remediator exposure during remediation estimated to be significant
Books and papers	3	Full Use professional judgment, consider potential for remediator/occupant exposure and size of contaminated area	Full Use professional judgment, consider potential for remediator exposure and size of contaminated area
Carpet and backing	1,3,4
Concrete or cinder block	1,3
Hard surface, porous flooring (linoleum, ceramic tile, vinyl)	1,2,3,4
Non-porous, hard surfaces (plastics, metals)	1,2,3
Upholstered furniture & drapes	1,2,4
Wallboard (drywall and gypsum board)	3,4
Wood surfaces	1,2,3,4
† Cleanup Methods
Select method most appropriate to situation. Since molds gradually destroy the things they grow on, if mold growth is not addressed promptly, some items may be damaged such that cleaning will not restore their original appearance. If mold growth is heavy and items are valuable or important, you may wish to consult a restoration/water damage/remediation expert. Please note that these are guidelines; other cleaning methods may be preferred by some professionals.
Method 1: Wet vacuum (in the case of porous materials, some mold spores/fragments will remain in the material but will not grow if the material is completely dried). Steam cleaning may be an alternative for carpets and some upholstered furniture.
Method 2: Damp-wipe surfaces with plain water or with water and detergent solution (except wood — use wood floor cleaner); scrub as needed.
Method 3: High-efficiency particulate air (HEPA) vacuum after the material has been thoroughly dried. Dispose of the contents of the HEPA vacuum in well-sealed plastic bags.
Method 4: Discard - remove water-damaged materials and seal in plastic bags while inside of containment, if present. Dispose of as normal waste. HEPA vacuum area after it is dried.
* Personal Protective Equipment (PPE)
Use professional judgment to determine prudent levels of Personal Protective Equipment and containment for each situation, particularly as the remediation site size increases and the potential for exposure and health effects rises. Assess the need for increased Personal Protective Equipment, if, during the remediation, more extensive contamination is encountered than was expected.
Minimum: Gloves, N-95 respirator, goggles/eye protection
Limited: Gloves, N-95 respirator or half-face respirator with HEPA filter, disposable overalls, goggles/eye protection
Full: Gloves, disposable full body clothing, head gear, foot coverings, full-face respirator with HEPA filter
** Containment
Limited: Use polyethylene sheeting ceiling to floor around affected area with a slit entry and covering flap; maintain area under negative pressure with HEPA filtered fan unit. Block supply and return air vents within containment area.
Full: Use two layers of fire-retardant polyethylene sheeting with one airlock chamber. Maintain area under negative pressure with HEPA filtered fan exhausted outside of building. Block supply and return air vents within containment area.
Source: U.S. Environmental Protection Agency. Adapted from http://www.epa.gov/mold/table2.html.

It is important to remember that the instructions in Table 1 assume mold that has been caused by an excess or inundation of clean water. If you are dealing with an area that has been flooded in a hurricane or other natural disaster or by dirty water (eg, sewage), consult the EPA Fact Sheet Flood Cleanup–Avoiding Indoor Air Quality Problems and the CDC website at http://www.bt.cdc.gov/disasters/mold/ for extensive information on appropriate procedures and safety measures.

Biocides

Biocides, such as chlorine bleach, are not recommended for routine use in cleaning up mold. A mild detergent solution and the appropriate cloths, sponges, or brushes (depending on the surface being cleaned) is the recommended procedure. Because mold is always present at background levels it is not considered desirable (or even possible) to sterilize an area. However, if the problem that caused the original moisture has been fixed, mold spores simply present in the air will not cause additional problems.

Under certain circumstances you (or a mold-removal professional) may determine that biocide use is appropriate, for example, when a facility is used by immuno-compromised persons. If biocides are used, appropriate precautions must be taken to ventilate the area and to use all substances in accordance with package directions and any local or state regulations (OSHA, 2003; CDC, 2006).

Other Considerations

If your cleanup needs are large or complex, you may want to consider hiring an experienced professional, especially if containment and high-level PPE are required. Familiarize yourself with the general procedures. Verify that anyone you hire is following EPA or other government and professional guidelines and check their references. If you are responsible for others in a building, be sure they are kept informed.

If your cleanup project involves an HVAC system, be sure the work is done by a professional experienced with those systems. Keep in mind that they may be using methods and materials that are not discussed here.

One final concern involves confined places, such as crawl spaces or pipe and valve areas. These areas offer the additional challenge of restricted movement and potentially poor ventilation. Use caution and consult a professional if necessary (EPA, 2007).

How Do You Know It's Really Clean?

OSHA suggests the following list for evaluating a cleanup job:

• You must have completely fixed the water or moisture problem.
• You should complete mold removal. Use professional judgment to determine if the cleanup is sufficient. Visible mold, mold-damaged materials, and moldy odors should not be present.
• If you have sampled, the kinds and concentrations of mold and mold spores in the building should be similar to those found outside, once cleanup activities have been completed.
• You should revisit the site(s) shortly after remediation, and it should show no signs of water damage or mold growth.
• People should be able to occupy or re-occupy the space without health complaints or physical symptoms.
• Ultimately, this is a judgment call; there is no easy answer. (OSHA, 2003)

PREVENTING MOLD

Once an area has been cleaned to remove all traces of mold, the priority is to take appropriate steps to prevent any regrowth.

In the Home

Homeowners and building occupants should observe the following guidelines to control moisture and prevent growth or regrowth of mold.

• Keep the building clean and dry.
• Watch for condensation and wet spots. Fix the sources of moisture problems as soon as possible.
• Keep the humidity between 40% and 60%.
• Use air conditioners and dehumidifiers as needed for season or location.
• Fix leaks in the roof, walls, windows, or plumbing.
• Ventilate bathrooms, kitchens, and laundry areas.
• Vent clothes dryer to the outside, if possible.
• Use mold-resistant paint (or add mold inhibitors before painting).
• Clean bathrooms with mold-killing products.
• Clean up and dry areas that are wet or have been flooded within 24 to 48 hours. Throw out anything that cannot be completely dried, including carpet and upholstery.
• Don't let foundations stay wet. Provide drainage and slope the ground away from the foundation.
• If you are not experienced with home/building repairs you may want to consult a professional when making repairs, or for assistance with mold-prevention–related changes to your home/building. (RIDH, n.d.; CDC, 2005; EPA, 2007)

In Institutional Settings

Clearly the list above applies in institutional as well as residential settings. In addition, commercial/public building managers should:

• Keep HVAC drip pans clean, flowing properly, and unobstructed.
• Perform regular building and HVAC inspections and maintenance as scheduled.

The Environmental Protection Agency (EPA) provides a variety of mold-related materials and tools, including software (I-BEAM) that can be used to help manage indoor air quality in large buildings, and the EPAIAQ (Indoor Air Quality) Tools for Schools.

In all cases, routine maintenance and repairs help reduce the possibility of problems.

CONCLUSION

Mold, and its potential physical and medical effects, is an issue of concern for many people: individuals, home and business owners; building maintenance managers; public health specialists; healthcare workers; disaster recovery specialists; even lawyers and architects. As researchers discover more about different kinds of molds and their effects on people and indoor environments, perhaps we will discover more effective ways to deal with associated problems. This is an evolving issue and the resources listed below can help you stay informed.

Posted May 20, 2008

Expires May 3, 2010

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