THE MERRY-GO-ROUND OF
DAMPNESS AND HEALTH
Carl Grimes, HHS, CIEC
cgrimes@haywardhealthyhome.com
Kevin Kennedy, MPH, CIEC
Kkennedy@cmh.Edu
National Healthy Homes Conference
Nashville, May 28-30, 2014
1
Indoor Environmental
Health &
Management are
part of upstream
healthcare
Are 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
REDUCTION
HOW DO YOU
DEFINE DAMPNESS?
5
Our Homes, and
How to Make Them
Healthy, Shirley
Forster Murphy,
Cassell & Company,
Ltd., London, 1883.
6
Women, plumbers, and
doctors: Household
sanitation
Mrs. H.M. Plunkett, d.
Appleton & Company,
New York, 1885.
7
Bowditch, Henry,
Public Hygiene in America,
Boston: Little, Brown, and
Company; 1877.
8
Plumbing and Household
Sanitation, John Pickering,
Doubleday, Page & Co. 1911.
9
Sir John Floyer,
A treatise on asthma
Pub. 1698
10
Vitruvius on Architecture
50 BCE
Hippocrates
150 BCE
11
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.
12
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
13
*Kennedy, K, C. Grimes, Indoor Water and Dampness and the Health Effects on Children:
A Review, Curr. Allergy Asthma Rep. (2013) 13:672–680.
SYSTEMATIC REVIEWS AND METAANALYSES
• 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 symptoms
Fisk WJ, et.al., Association of residential dampness and mold with respiratory tract infections and bronchitis: a meta-analysis.
14
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.
Health Outcome IOM 2004 conclusion
WHO 2008 conclusion
Mendel (2011)
Additional evidence
(None)
(None)
(None)
Sufficient evidence of a causal (None)
relationship
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
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 Initial evaluation
of association
Allergy/atopy
Not evaluated
Not evaluated
Initial evaluation
Altered lung
function
(Association based on clinical
evidence)
(Association based on clinical
evidence)
Inadequate or insufficient
(None)
evidence to determine whether
an association exists
Hypersensitivity
pneumonitis
Sufficient evidence of
association
Sufficient evidence of association
Sufficient evidence of
association
Sufficient evidence of
association
Initial evaluation
15
*Mendell MJ, et.al., Mold and Dampness-related agents: A Review of the epidemiologic evidence, Environ Health Perspect., 2011 (6):748–756
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.
16
WHO Guidelines for Indoor Air Quality: Dampness and Mould. Geneva. World Health Organization, 2009.
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 asthma
Jaakkola 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
17
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
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 doctordiagnosed 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 parents
Dales R, et. al. Residential fungal growth and incidence of acute respiratory illness during the first two years of life.
Environ
18
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.
Research Methods To Characterize Dampness
19
Research Methods To Characterize Dampness
20
Dampness is Not a “Thing”
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?
21
WHO 2009 IAQ And Dampness And Mold
Key Components to Assessment:
• Observation
• Survey
• Role of measurements - are there measurements and
how to interpret?
22
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
23
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.
24
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
25
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.
Temperature Isn’t Comfort, Its Energy
40˚
80˚
F
F
Higher Temp., more Kinetic Energy
27
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
28
29
USED WITH PERMISSION FROM LEW HARRIMAN, MASON GRANT
CONSULTING
ALTERNATE DAMPNESS MEASUREMENTS?
• Moisture content
• Surface temp and relative
humidity
• Absolute humidity
• Water activity (AW)
30
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.
31
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.
32
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 dampnessrelated health risks.
33
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.
34
THE MERRY-GO-ROUND OF
DAMPNESS AND HEALTH
Carl Grimes, HHS, CIEC
cgrimes@haywardhealthyhome.com
Kevin Kennedy, MPH, CIEC
Kkennedy@cmh.Edu
National Healthy Homes Conference
Nashville, May 28-30, 2014
35