the merry-go-round of dampness and health kevin kennedy, mph, ciec kkennedy@cmh.edu 1 carl grimes,...

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THE MERRY-GO-ROUND OF

DAMPNESS AND HEALTH

Kevin Kennedy, MPH, CIEC

Kkennedy@cmh.Edu

Carl Grimes, HHS, CIECcgrimes@haywardhealthyhome.com

National Healthy Homes ConferenceNashville, May 28-30, 2014

Indoor Environmental Health & Management are part of upstream healthcareAre you an

Upstreamist?

PATHWAYS LINKING SOURCES OF DAMPNESS WITH HEALTH

From- WHO Guidelines for IAQ: Dampness & Mold, p.4-5, 2009

THE GOAL IS

EXPOSURE REDUCTIO

N

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HOW DO YOU DEFINE

DAMPNESS?

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Our Homes, and How to Make Them Healthy, Shirley Forster Murphy, Cassell & Company, Ltd., London, 1883.

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Women, plumbers, and doctors: Household sanitation

Mrs. H.M. Plunkett, d. Appleton & Company,

New York, 1885.

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Bowditch, Henry,

Public Hygiene in America, Boston: Little, Brown, and Company; 1877.

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Plumbing and Household Sanitation, John Pickering, Doubleday, Page & Co. 1911.

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Sir John Floyer,

A treatise on asthma

Pub. 1698

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Vitruvius on Architecture 50 BCE

Hippocrates

150 BCE

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MODERN HISTORY OF DAMPNESS

Institute of Medicine, Damp Indoor Spaces And Health, 2004

• Did not define dampness

• Newer research has not provided consistent or consensus agreement on dampness.

No description, definition, or measurement of dampness has been proposed.

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LITERATURE REVIEW- DAMPNESS & CHILDREN’S HEALTH 2010 – 2013*

Literature on health outcomes in children and dampness as described by various metrics:

• How was dampness defined and/or described

*Kennedy, K, C. Grimes, Indoor Water and Dampness and the Health Effects on Children:A Review, Curr. Allergy Asthma Rep. (2013) 13:672–680.

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SYSTEMATIC REVIEWS AND META-ANALYSES

• Additional reviews and meta-analyses showing association between dampness and mold by various metrics and:

• Upper respiratory tract symptoms, cough, wheeze, asthma development, current asthma and ever diagnosed asthma, bronchitis, allergic sensitization, hay fever, cough, wheeze, and allergic respiratory symptomsFisk WJ, et.al., Association of residential dampness and mold with respiratory tract infections and

bronchitis: a meta-analysis. Environ Health. 2010; 15; 9:72 1476-069.Tischer C G, et.al. Metaanalysis of mould and dampness exposure on asthma and allergy in eight

European birth cohorts: an ENRIECO initiative. Allergy. 2011;66 (12) 1570–1579.

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Health Outcome   IOM 2004 conclusion   WHO 2008 conclusion   Mendel (2011) Additional evidence(None) (None) (None) Sufficient evidence of a causal

relationship (None)

asthma exacerbation Sufficient evidence of association

Sufficient evidence of association Sufficient evidence of association

More studies of strong design (suggestive of causation)

Cough Sufficient evidence of association

Sufficient evidence of association Sufficient evidence of association

Many new studies, some of strong design

Wheeze Sufficient evidence of association

Sufficient evidence of association Sufficient evidence of association

Many new studies, many of strong design

Upper respiratory tract symptoms

Sufficient evidence of association

Sufficient evidence of association Sufficient evidence of association

Many new studies, some of strong design

Asthma development

Limited or suggestive evidence of association

Sufficient evidence of association

Sufficient evidence of association

More studies of strong design

Dyspnea Limited or suggestive evidence of association

Sufficient evidence of association Sufficient evidence of association

More studies Initial evaluation

Current asthma Not evaluated Sufficient evidence of association Sufficient evidence of association

Initial evaluation

Ever-diagnosed asthma Not evaluated Not evaluated Initial evaluation

Respiratory infections

Not evaluated Sufficient evidence of association Sufficient evidence of association

Initial evaluation

Bronchitis Not evaluated Limited or suggestive evidence of association

Initial evaluation

Allergic rhinitis Not evaluated Limited or suggestive evidence of association

Initial evaluation

Eczema Not evaluated Not evaluated Initial evaluation

Common cold Not evaluated Not evaluated Limited or suggestive evidence of association

Initial evaluation

Allergy/atopy Not evaluated Not evaluated Initial evaluation

Altered lung function

(Association based on clinical evidence)

(Association based on clinical evidence)

Inadequate or insufficient evidence to determine whether an association exists

(None)

Hypersensitivity pneumonitis

Sufficient evidence of association

Sufficient evidence of association Sufficient evidence of association

*Mendell MJ, et.al., Mold and Dampness-related agents: A Review of the epidemiologic evidence, Environ Health Perspect., 2011 (6):748–756

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WHO 2009 and The Latest Key Findings

Still relatively large number of studies that have failed to demonstrate a direct association between bioaerosol concentrations and health effects in damp indoor environments.

WHO Guidelines for Indoor Air Quality: Dampness and Mould. Geneva. World Health Organization, 2009.

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From Population & Case-control Studies

• Presence of visible molds and perceived mold odor were shown to be independently and significantly associated with the incidence of asthma in children

• Early-onset childhood asthma was found to be significantly associated with a number of environmental exposures including visible mold, mildew odors, cockroaches, carpet, pets and environmental tobacco smoke.

• Reported exposure to mildew odors was shown to have a great influence on early-onset asthmaJaakkola JJ, et. al. Home dampness and molds as determinants of allergic rhinitis in childhood: a 6-

year, population-based cohort study. Am J Epidemiol. 2010;172(4) 451–459 Chen YC, et.al. Early-life indoor environmental exposures increase the risk of childhood asthma.

Int. J Hyg Environ Health. 2011;215(1):19–25.21.Hwang BF, et. al. Molds, parental atopy and pediatric incident asthma. Indoor Air. 2011; 21(6) 472–

478

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From Quantitative Measurement Studies

• Majority of recent studies that used quantitative measures of indoor dampness and mold did not find a significant association with health.

• For example, no association was found between doctor-diagnosed asthma/allergy in children and indoor mold spore exposure (colony-forming unit) and different indexes of visible signs of dampness and/or indoor moldy odor, either observed by professional inspectors or reported by parentsDales R, et. al. Residential fungal growth and incidence of acute respiratory illness during the first

two years of life. Environ Res. 2010; 110(7) 692–698.Holme J et.al. Culturable mold in indoor air and its association with moisture-related problems and

asthma and allergy among Swedish children. IndoorAir. 2010;20(4):329–40.

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Research Methods To Characterize Dampness

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Research Methods To Characterize Dampness

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It Is A Composite Of…• Water in liquid, solid, or gaseous form.

• In air, on surfaces, absorbed beneath a surface

• Extent – S500 class 1, 2, and 3.

• Time – how long has it been there?

• Type of water – s500 category 1, 2, 3, special.

• Temperature – how warm or cold?

Dampness is Not a “Thing”

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WHO 2009 IAQ And Dampness And Mold

• Observation

• Survey

• Role of measurements - are there measurements and how to interpret?

Key Components to Assessment:

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Erratic Agreement Between Occupant And Trained Assessor’s Perception

WHO discussion (page 9)- Occupants reported more dampness than the

trained surveyors (bornehag et al., 2001),

Some studies showed that occupants reported less dampness (williamson et al., 1997; nevalainen et al., 1998).

Other studies showed poor agreement between self-reported and inspectors’ observations of dampness and moldy odor. (Engman, bornehag and sundell (2007) and sun, sundhell and zhang (2007) .From- WHO Guidelines for IAQ: Dampness & Mold, p.8,

2009

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AIHA “GREEN BOOK”• Indoor exposures are a complex mixture of molds, bacteria,

fragments of both types of organisms; their multiple toxic products; and biologically derived small particles, gases and other air pollutants. Effects, depending on the susceptibility of the exposed occupants and their degree of exposure, can be combinations of allergic response, inflammation and its consequences, and other toxic responses. This complex exposure and effect picture is not addressed by risk assessment focused on spores or individual toxins.*

• The implications of this research are that prevention of unwanted moisture, and removal of filth caused by moisture, is necessary to prevent disease.**

(Emphasis added)*Chapter 1, Section 1.3.5, Recognition, Evaluation, and Control of Indoor Mold, AIHA, 2008.

**Chapter 1, Section 1.3.5, Recognition, Evaluation, and Control of Indoor Mold, AIHA, 2008.

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Remember The Truth About Relative Humidity

• Relative humidity is measure of energy taken up by water to convert it to a gas, not holding capacity…

• Warm air evaporates more water because there is more thermal energy available to do the work of evaporation

Remember Psychrometrics Is…

The study of the physical and thermodynamic properties of air-water vapor mixtures. Atmospheric gases and water vapor (gas) exist in the same spaces all around us and can be looked at as a mixture of dry air and water vapor.

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Temperature Isn’t Comfort, Its Energy

Higher Temp., more Kinetic Energy

40˚F

80˚F

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Relative Humidity Is A Dynamic Value

A relative humidity of 50% means half the available energy has been used to evaporate water from surfaces and anywhere else, and 50% of the energy is still available to do more evaporation

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USED WITH PERMISSION FROM LEW HARRIMAN, MASON GRANT CONSULTING

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ALTERNATE DAMPNESS MEASUREMENTS?

• Moisture content

• Surface temp and relative humidity

• Absolute humidity

• Water activity (AW)

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ASHRAE MOLD POSITION STATEMENT

• This position document provides help in understanding some of the complex interactions and decisions that lead to indoor dampness. However, professionals and the public need to know, with greater certainty than at present, when a building is “dry enough” to avoid dampness-related health risks.

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ASHRAE MOLD POSITION STATEMENT

• ASHRAE recommends further health-related building research to develop and publish a practical, quantitative, and effective definition and measurement technique for whole-building dampness … the goal should be to develop and publish a quantitative definition of a “damp building,” together with an economically practical measurement technique.

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ASHRAE MOLD POSITION STATEMENT

• To be useful in the real world of building design, construction and operation, such a definition and measurement technique must allow determination (with reasonable and repeatable certainty) of a building that is “dry enough” to avoid dampness-related health risks.

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Retain The Term “Dampness,” But…

• Dampness is a familiar, colloquial, generic term that easily and quickly communicates a complex situation.

• But, neither studies nor building assessments should attempt to measure it. Because “it” can’t be measured.

• However, the various components can be.

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THE MERRY-GO-ROUND OF

DAMPNESS AND HEALTH

Kevin Kennedy, MPH, CIEC

Kkennedy@cmh.Edu

Carl Grimes, HHS, CIECcgrimes@haywardhealthyhome.com

National Healthy Homes ConferenceNashville, May 28-30, 2014