· CDC’s perspective on the state of the science relating to mold and health effects in people;

· CDC’s efforts to evaluate health problems associated with molds,

· CDC’s collaborations with other Federal agencies related to mold and people’s health;

· CDC’s collaboration with the Institute of Medicine on mold and health; and

· CDC’s next steps regarding mold and health.

            Molds can cause illnesses in situations other than humid indoor environments. We have documented that molds can cause infections in susceptible people, particularly in hospital settings where 9% of hospital-acquired (nosocomial) infections are caused by fungi. Respiratory infections due to inhalation of the fungus Aspergillus have been documented mostly in immunocompromised individuals. Molds also have been associated with some cancers. Two mold-produced toxins (aflatoxins and ochratoxin A) have been classified by the National Toxicology Program as human carcinogens (http://ntp-server.niehs.nih.gov/). Chronic ingestion of these toxins from eating contaminated foods has been associated with liver and kidney tumors in animals and people.

            Outbreaks of hypersensitivity pneumonitis also have been reported in office buildings in relation to exposures to mold-contaminated humidifiers and ventilation systems (Arnow et al. 1987. Early detection of hypersensitivity pneumonitis in office workers, American Journal of Medicine 64:236-242 and Hodgson et al. 1987. An outbreak of recurrent acute and chronic hypersensitivity pneumonitis in office workers. American Journal of Epidemiology 125:631-638)).

           We also know that molds can cause illness when people are exposed to extensive mold growth indoors. In its 1993 report "Indoor Allergens," the Institute of Medicine (IOM) concluded that airborne fungal allergens were most often associated with allergic diseases, such as allergic rhinitis/conjunctivitis, allergic asthma, and hypersensitivity pneumonitis. In its 2000 report "Clearing the Air: Asthma and Indoor Air Exposures," IOM concluded that there is sufficient evidence of an association between exposure to mold and exacerbations of asthma. The IOM also stated that there was inadequate evidence that molds caused people to become asthmatic.

            Exposure to mold does not always result in a health problem. However, routine measures should be taken to prevent mold growth indoors because some people are, or may become, allergic to it. For people who are allergic to mold, common effects include hay-fever-like allergic symptoms. Certain individuals with chronic respiratory disease (chronic obstructive pulmonary disease or asthma) may experience difficulty breathing when exposed to mold. Also, people with immune suppression or underlying lung disease are more susceptible to fungal infections.

            CDC has conducted several activities related to mold in wet indoor environments and its effect on people’s health.

           ·In July 2001, following flooding in North Dakota, CDC investigated Turtle Mountain Reservation residents’ concerns that mold contaminating their homes might be contributing to an increase in illness among tribal members. CDC assessed both the physical and environmental condition of the homes to identify any environmental hazards, including the presence of mold, and collected information on health conditions of the individuals living in the homes. An interim report identified several existing hazards unrelated to mold and made recommendations to address these hazards. The final report is expected in October 2002. In addition to working with the Indian Health Service and the Federal Emergency Management Agency (FEMA) on this project,

            ·CDC also worked with the U.S. Department of Housing and Urban Development (HUD) to identify procedures that might be implemented to assess conditions of HUD homes that would help to prevent mold.

           · CDC responded to a request from the State of Texas and the City of Houston in the summer of 2001, after the city experienced significant flooding, to assess the conditions of the buildings and provide advice on cleanup and repair of affected buildings. The emphasis of this technical assistance was cleanup and prevention of further mold growth and prevention of unnecessary exposure.

           So far, the results include the following:

           · there were significant relationships between reports of work-related respiratory disease and visual assessment of water and mold-damage in two studies;

            · there were significant relationships between endotoxin and ultra-fine particles in air and work-related respiratory symptoms; and

            · there were significant relationships between indicators of mold in chair and floor dust and work-related respiratory symptoms.

            · CDC is planning an occupational and environmental research project regarding bioaerosols in

schools to address children’s and teacher’s health issues.

            · CDC is working to address indoor air quality issues, including mold, in partnership with stakeholders through the National Occupational Research Agenda (NORA). NORA efforts have resulted in development of the research priorities paper, "Improving the Health of Workers in Indoor Environments: Priority Research Needs for a National Occupational Research Agenda," which identifies important areas for future research. The paper has been accepted for publicationin the American Journal of Public Health (AJPH).

           CDC is working with federal, state, local, and tribal governments to investigate and respond to mold-related problems. I have already mentioned that we work with HUD, FEMA, and the Indian Health Service on mold issues. We have also assisted the U.S. Environmental Protection Agency (EPA) Indoor Environments Division in the development of a guide for mold remediation in schools and large buildings and in the development of a brief guide to mold for homeowners. CDC is participating in the development of a World Health Organization guidance document on exposures to biological agents in the indoor environment; this document should be finalized in the year 2003. CDC also has worked with the Council of State and Territorial Epidemiologists in the development of case definitions and classifications for pulmonary hemorrhage in infants.

            In response to concerns about mold and the gaps in scientific knowledge, CDC is currently developing an agenda for research, service, and education related to molds. The results of this effort will ultimately enable CDC to (1) make recommendations for reducing mold contamination, (2) identify environmental conditions that contribute to the occurrence of disease following mold exposure, and (3) assist state and local health departments in improving their capacity to investigate mold exposures. CDC is working to help strengthen state and local capacity to respond to requests regarding molds. Because there are no quantitative standards, guidelines or uniform recommendations for responding to mold in indoor environments, each state or local health department responds to public inquiries based solely on its own experience. CDC is working with the Council of State and Territorial Epidemiologists to:

            · develop an inventory of state Indoor Air Quality programs;

            · determine the extent to which these programs are coordinated to respond to issues related to indoor mold exposures;

            · identify resources that states need in order to develop and implement appropriate responses; and

            · develop a coordinated public health response strategy to mold exposure.

            CDC will continue to investigate and evaluate the health effects of and quantify the risks associated with, exposure to mold and poor indoor air. The expectation is that such studies will help to identify the environmental factors and antecedents associated with mold contamination and factors that determine poor health outcomes. For example, CDC is developing a protocol for investigating the possible health effects of exposure to mold in indoor school environments. CDC will use the knowledge, experience and skill gained from these investigations and evaluations to translate science-based findings into appropriate public health interventions to reduce any health risk found to be associated with mold exposure.

            There are a number of barriers that need to be overcome in investigating the possible effects of molds on health. There are no accepted standards for mold sampling in indoor environments or for analyzing and interpreting the data in terms of human health. Molds are ubiquitous in the environment, and can be found almost anywhere samples are taken. It is not known, however, what quantity of mold is acceptable in indoor environments with respect to health. Because of difficulties related to sampling for mold, most studies have tended to be based primarily on baseline environmental data rather than human dose-response data. For these reasons, and because individuals have different sensitivities to molds, setting standards and guidelines for indoor mold exposure levels is difficult and may not be practical. Despite the lack of standards,

            CDC concurs with EPA’s recommendation to remedy mold contamination in indoor environments to prevent negative health effects.

            We do know that people who are exposed to molds may experience a variety of illnesses. Fungi account for 9% of nosocomial infections, that is, infections originating or taking place in a hospital. Ingestion of foods contaminated with certain toxins produced by molds is associated with development of human cancer. Many respiratory illnesses among workers may be attributed to mold exposures. Uncommon illnesses that collectively can be called hypersensitivity pneumonitis are caused by chronic exposures to high concentrations of mold and are almost exclusively limited to certain agricultural workers in particularly moldy environments. Common illnesses caused by molds include allergic conditions such as hay fever and asthma.

           Because molds can be harmful, CDC concurs with the general recommendations of agencies such as EPA and FEMA, which offer information on preventing and cleaning up mold growth in indoor environments. Linkages between indoor airborne exposures to molds and other health effects, such as bleeding from the lung, or memory loss, have not yet been scientifically substantiated. CDC and other organizations are taking steps to fill the gaps in our knowledge about linkages between exposure to mold and human health.

            Thank you again for the opportunity to testify. I would be happy to answer any questions that you have.