June 22, 2011

Ellen M. Wells, Matt Berges, Stephen Vesper, Iwona Yike, H. Lester Kirchner, Stuart Greenberg, Dorr G. Dearborn

Long term follow-up of home environmental remediation for mold & moisture

Long term follow-up of home environmental remediation for mold & moisture

PRESENTATION OUTLINEBackgroundUMMPUMMP IIConclusions

Ellen M. Wells1, Matt Berges2, Stephen Vesper3, Iwona Yike1, H. Lester Kirchner4, Stuart Greenberg2, Dorr G. Dearborn1

1: Swetland Center for Environmental Health, CWRU School of Medicine; Cleveland, OH 2: Environmental Health Watch; Cleveland, OH 3: US Environmental Protection Agency; Cincinnati, OH 4: Geisinger Medical Center, Danville, PA

Urban Mold and Moisture Project II

PARTNERSSwetland Center for Environmental Health, CWRU School of Medicine, granteeEnvironmental Health WatchUniversity HospitalsCuyahoga County Board of HealthUS Environmental Protection AgencyCuyahoga County Department of Development

FUNDERSHUD Office of Healthy Homes and Lead ControlUS Environmental Protection Agency

BACKGROUND

Moisture in the home

At least 20% of U.S. buildings have signs of dampness

Moisture is more likely with• Overcrowding• Insufficient heating, ventilation, and insulation

A Cleveland Perspective• Older housing stock• High poverty levels For more information, see: Guidelines for Indoor Air Quality:

Dampness and Mould, World Health Organization, 2009; Damp Indoor Spaces and Health, Institute of Medicine, 2004

www.ehw.org

Extent of the issue

Moisture in the home

Consequences of excess moisture • Leads to microbial growth (mold)• Initiates chemical or biological degradation of materials• Encourages presence of pests

Presence of dampness is considered to be a risk factor for asthma and respiratory disease

For more information, see: Guidelines for Indoor Air Quality: Dampness and Mould, World Health Organization, 2009; Damp Indoor Spaces and Health, Institute of Medicine, 2004

Connection with health

Fungi (i.e., mold)

Ubiquitous eukaryotic organismsHundreds of different speciesGrowth limited by temperature, nutrients,

moistureHealth effects include• Infections, allergies, toxicities

Health effects may arise from• Viable (live), or nonviable (dead) or fragments of organismsFor more information, see: Guidelines for Indoor Air Quality:

Dampness and Mould, World Health Organization, 2009; Damp Indoor Spaces and Health, Institute of Medicine, 2004

URBAN MOLD & MOISTURE PROGRAM

Urban Mold & Moisture Program

Components of the program• Visual inspections of homes• Homes sampled for mold• Moisture reduction interventions• Monitoring respiratory health

Will reduction of moisture in homes improve homes and health?

Leaks Cooking, Bathing,Watering Plants,Breathing,Washing

Surface water

Groundwater

Air From Soil

Urban Mold & Moisture Program

Repair the “Cleveland drop”Flash the soil to the houseTreat the porch like a roofEliminate sub-slab duct and heating systemsDisconnect and redirect downspoutsReduce moisture in crawlspacesCorrect negative grade at foundationRemove debris in basementsVent clothes dryer to exteriorOccupant education

Moisture intervention goals

Urban Mold & Moisture Program

Randomized controlled trialEligibility criteria

• Children hospitalized for asthma within the past year• Mold visible in the home

All children (n=62) had medical care optimizedRoughly half (n=29) of the homes were remediated

• Children assessed at 6 and12 months• Homes reassessed at 12 months

For more information, see: Kercsmar et al. 2006. Environmental Health Perspectives 114(8):1574-1580.

A subset of the program where families had asthmatic children

Urban Mold & Moisture Program

Significant decrease in symptom days (p = 0.004) after repairs

Lower rate of ER visits and hospitalizations • Remediation group: 1 of 29 • Control group: 11 of 33, p = 0. 003).

Outcomes from asthma study

For more information, see: Kercsmar et al. 2006. Environmental Health Perspectives 114(8):1574-1580.

URBAN MOLD & MOISTURE PROGRAM II

Urban Mold and Moisture Project II

Sustainability/maintenance of housing improvements

Do these interventions need to be modified?

Home visual inspections to identify moldSampling for mold and moistureMaintenance of respiratory symptom

improvements

Are home moisture interventions effective 5 to 8 years later?

UMMP II

104 homes renovated in 2000-5

44 (42%) visited in 2008-9• 28 (63.6%) with original

families • 16 (36.4%) with new families

Data collected at the visits• Visual inspection for mold• Dust sampling for mold• Occupant questionnaire• Visual assessment of

interventions

Housing interventions

Repair of the “Cleveland drop”• Did not require maintenance

• All were still in place and functional

Eliminate sub-slab duct work• Concrete in holes in duct work, new

furnace

• All were still in place and functional

Interventions still in working order

For more information, see: “Moisture Control in Older Housing: Observations of a Five Year Follow Up”, Environmental Health Watch, www.ehw.org

Housing interventions

Flash the soil to the house• Poor implementation can exacerbate problem• Flat trenches, rubber ending near foundation

Treat the porch like a roof• Temperature gradients may still cause moisture

Reduce moisture in crawl spaces• Use of plastic may trap water from other sources• Including ‘rat slabs’ could help prevent pests

Correct negative grade at foundation• Not every grade was completely corrected• Maintenance also needed to maintain these

Functional, but some improvements needed

For more information, see: “Moisture Control in Older Housing: Observations of a Five Year Follow Up”, Environmental Health Watch, www.ehw.org

Housing interventions

Disconnection, redirection of downspouts• Most common problem • Not maintained, occasionally missing• Some implementations exacerbate problem• Location can be a problem for other activities

Remove debris from basement• Staff occasionally not allowed into basement• Several basements still had debris

Vent clothing dryer to outside• Common for the vent to become disconnected• In some cases this was intentional

Post-intervention events contributed to failure

For more information, see: “Moisture Control in Older Housing: Observations of a Five Year Follow Up”, Environmental Health Watch, www.ehw.org

Visual inspections for mold

Room 5-8 years vs. baseline 5-8 years vs. clearance

Basement, any surface Significant decrease Significant decrease

Basement, cellulose Significant decrease Significant decrease

Kitchen Significant decrease Decrease

Bathroom Significant decrease Decrease

Symptom questionnaires

Given to families with a new infant, mold in the homeBaseline, 1 year and 5-8 years following remediationLimited to those who had not moved 5-8 years later

(n=56)General symptoms

• Several symptoms decreased at 1 year, but not 5-8 years later

Respiratory symptoms• Most significantly improved at 1 year, but no significant

improvement from baseline at 5-8 years• ‘A lot of mucus of phlegm’, ‘shortness of breath or rapid

breathing’ showed significant improvement at 5-8 years (v. baseline)

Asthma exacerbations

Repeated interviews among 26 families with interventions• 16 had moved, 10 had not moved• Exacerbation = ER visit or hospitalization

Among those who had moved• 6 out of 16 children (37.5%) had a total of 10

exacerbations

Among those who had not moved• 2 out of 10 children (20.5%) had a total of 3

exacerbations

Analysis of mold in dust

QPCR analysis of 33 mold species in homes of asthmatic children

Bedroom TV/Living room

Clearance vs. baseline Significant decrease (5 spp)

5-8 years vs. clearance Significant decrease (3 spp)Significant increase (20 spp)

5-8 years vs. baseline Significant decrease (1 spp)Significant increase (20 spp)

CONCLUSIONS

Conclusions, part 1

Sustainability of housing interventions• Overall these houses remain in better condition• Consider interventions not requiring maintenance even if

more cost• Education regarding the purpose, maintenance of

interventions

Occurrence of self-reported respiratory symptoms• In most cases, a decline at 1 year was not maintained

There are long term benefits to moisture interventions; however, maintenance continues to be an issue

Conclusions, part 2

Asthma exacerbations among those in renovated homes• Fewer exacerbations among those still in renovated homes

compared to those who moved

Presence of mold in homes of asthmatics• A few species had lower concentrations • Many species increased in concentrations compared to

baseline or just post clearance

Acknowledgements

Jodi Lavrich Mia GellesDebrah MuhammadMargaret PizziAkbar Tyler