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Increased awareness, education needed regarding hazardous effects of mold
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In 2012, it seems hard to believe that some, notably in the insurance industry, still fail to acknowledge the strong relationship between mold and many serious childhood respiratory health problems, including infant pulmonary hemorrhage.
Florence Nightingale (1820-1910), who worked in the 19th century, clearly recognized the importance of the connection between living conditions and health. More than 100 years ago, she taught about the six Ds of disease: dirt; drink (clean drinking water); diet; damp; drafts; and drains (proper drainage and sewage systems). Although the reason these were important may not have been fully understood in those days, we now have substantial evidence demonstrating that many important advances in public health, such as increases in life expectancy and lower mortality rates, have been built on improvements in living conditions, such as clean drinking water, proper drainage and sewage systems, and adequate diet. Today, however, inadequate attention is paid to damp environments.
Hazards of damp environments
Damp environments are unhealthy because they promote the growth of molds. Despite what Nightingale and others taught a century ago, mold is currently considered by many to be a household nuisance, but hardly a health hazard. Current evidence, gathered during the past 20 years, suggests that exposures to mold may not be so innocuous, especially during the earliest period of life. Exposure to molds in the indoor air of the home has been linked to the development of serious pulmonary hemorrhage among infants who live in damp, water-damaged places.
Ruth Etzel
Pulmonary hemorrhage is a medical emergency in otherwise healthy infants aged 2 to 3 months. A small amount of blood coming from the infant’s nose or mouth can be an indication of pulmonary hemorrhage. Sometimes, no blood is visible, but the infant suddenly becomes limp, lethargic and pale, and grunts or stops breathing. This apparent life-threatening event usually requires admission to the hospital and respiratory support. A normocytic, normochromic anemia is common.
Until recently, because infant pulmonary hemorrhage is rare, few etiologic studies were conducted. A cluster of eight cases in Cleveland in the early 1990s provided the opportunity to undertake a case-control study that identified exposure to molds in the indoor environment as a risk factor for infant pulmonary hemorrhage. A re-analysis of the data by a second group of independent analysts confirmed the statistically significant association between exposure to molds and pulmonary hemorrhage.
How might it be possible for molds to lead to pulmonary hemorrhage? Some molds produce very potent chemicals (mycotoxins) that preferentially affect rapidly dividing cells. Because the lung is growing very fast during the first few months of life, babies are uniquely susceptible to pulmonary hemorrhage during that period.
Supporting evidence
Several case reports that lend support to this association have appeared in the literature. Exposure to household molds has been linked to acute pulmonary hemorrhage among young infants in Kansas City, Mo., and Delaware. A case of acute pulmonary hemorrhage in a North Carolina infant was associated with exposure to a moldy home from which Trichoderma, a toxin-producing fungus, was isolated. Cases have also been reported from New Zealand and Oman. Stachybotrys, another toxin-producing fungus, has been isolated from the bronchoalveolar lavage fluid of a 7-year-old child with lung bleeding and pulmonary hemosiderosis in Houston. Although infants are most vulnerable, in one study from Hungary, nose bleeds were documented among adult workers exposed to aerosols of Stachybotrys in contaminated hay.
Infants with pulmonary hemorrhage must be removed from damp, moldy environments. A significant reduction in recurrent pulmonary hemorrhage has been demonstrated following the recommendation that infants with pulmonary hemorrhage be removed from the residence where the infant was living when the hemorrhage occurred. Before routine recommendations to move, five of seven infants in Cleveland had recurrent pulmonary hemorrhage. After the recommendation to move, one of 21 had recurrent hemorrhage.
Additional awareness needed
Public health efforts in the past 20 years to educate parents and pediatricians about the effects of mold on young children have been partially successful. Much more is necessary, however, to overcome the continued lack of serious attention and misinformation. The recognition of the deleterious effects of damp environments on health in the 19th century was partially due to the everyday experiences of health practitioners in coping with illnesses associated with treacherous living and working conditions during the industrial revolution.
The relationship of health to the broader social context could hardly be avoided, particularly with respect to the systematic and patterned effects of those conditions. In addition, public health was more closely connected to social reformers concerned with large-scale efforts to change social conditions, rather than the effects of individual diseases. Today, the problem of mold crosses all social strata, even if disproportionately among the poor. Yet now we have powerful industries that have a vested interest in denying the dangerous effects of dampness and mold, not unlike the tobacco industry’s early campaigns.
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Ruth A. Etzel, MD, PhD, is a senior officer for environmental health research in the department of public health and environment for WHO. She is also research director for the Southcentral Foundation at the Alaska Native Medical Center in Anchorage, Alaska.Disclosure: Etzel reports no relevant financial disclosures.