Damp Indoor Spaces and Health (2004) / Chapter Skim
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5 Human Health Effects Associated with Damp Indoor Environments
5 Human Health Effects Associated with Damp Indoor Environments
Pages 183-269
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From page 183... ...
Previous chapters of this report have addressed the scientific literature regarding the biologic and chemical agents encountered in damp indoor environments: the factors influencing their presence or release, actions that can be taken to prevent or remediate contamination by them, the means available to characterize human exposure to them, and their toxic properties. This chapter evaluates the strength of the scientific evidence concerning the possible association between the agents and adverse health outcomes.
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From page 184... ...
Indoor environments are complex. They subject occupants to multiple exposures that may interact physically or chemically with one another and
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From page 185... ...
Thus, when the committee draws conclusions about the association between damp indoor environments and health outcomes, it is not imposing the assumption -- and readers should not presume -- that these outcomes are necessarily associated with exposure to a specific microbial agent or to microbial agents in general. When an association between a particular indoor dampness-related agent and a particular health outcome is addressed, it is specified in the text.
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From page 186... ...
Fungi and other microbial agents are omnipresent in the environment, and the committee restricted its evaluation to circumstances that could be reasonably associated with damp indoor environments. Studies regarding homes, schools, and office buildings were considered; such other indoor environments as barns, silos, and factories -- which may subject people to high occupational exposures to organic dusts and other microbial contaminants -- were not.
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From page 187... ...
A self-report of dampness or visible mold, for example, may indicate rather a wide range of potential exposures: particular molds, endotoxin, gram-negative bacteria, microbial VOCs, house dust mites, and dampnessrelated chemical releases from building materials, among others. Except in cases where studies carefully separate dampness-related exposures or where specific biomarkers of exposure exist, it can be difficult to identify the responsible agent and even then the identification of the agent may be problematic.
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From page 188... ...
Similarly, objective clinical measures have not been widely used to investigate gastrointestinal, dermatologic, rheumatologic, or neurologic complaints. A variety of biologic markers of inflammation are increasingly being applied to measure the effects of exposure to dampness and dampnessrelated agents in indoor environments (Purokivi et al., 2001; Roponen et al., 2001a; Trout et al., 2001; Wålinder et al., 2001)
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From page 189... ...
RESPIRATORY SYMPTOMS Respiratory symptoms -- possible indications of disease rather than disease itself -- have been ascribed to numerous agents found in and characteristics of indoor environments. This section divides them between upper respiratory tract (URT)
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From page 190... ...
damp stains or water damage for allergic rhinitis 1.28 (1.09–1.47) for common cold ≥ 4 times per year Rylander and 304 children Self-reported humidity 2.71 (1.07–6.91)
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From page 191... ...
for 19 office buildings nasal congestion or runny nose Self-reported flooding 1.55 (0.79–3.06) for nasal congestion or runny nose Wieslander et al., 1999 95 staff members in Measured dampness in concrete 1.10 (1.15–1.45)
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From page 192... ...
for children preceding year nasal congestion; 2.38 (1.13–4.99) for nasal excretion Self-reported water damage 4.60 (2.57–8.22)
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. The ability to smell can be tested and measured, but the method has not been applied in studies of dampness or mold in indoor environments, so interpretation of results is problematic.
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From page 194... ...
• There is sufficient evidence of an association between the presence of "mold" (otherwise unspecified) in a damp indoor environment and upper respiratory tract symptoms.
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From page 195... ...
for persistent cough Gunnbjörnsdottir et al., 1,853 young adults Self-reported water damage or 2.23 (1.24–4.00) 2003 visible mold in home (n = 74)
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From page 196... ...
major water leakage Dales and Miller, 1999 403 elementary-school Self-reported mold or mildew 1.28 (0.74–2.23) for children nocturnal cough or wheeze Koskinen et al., 1999a 699 adults (16+ years old)
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From page 197... ...
Andriessen et al., 1998 1,614 children Self reported moisture stains 1.01 (0.89–1.16) (5–13 years old)
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From page 198... ...
problem Jaakkola et al., 1993 2,568 preschool children Self-reported mold odor in 3.88 (1.88–8.01) for past year persistent cough Self-reported water damage 2.54 (1.16–5.57)
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(2 vs 0) Dijkstra et al., 1990 775 children Self-reported damp stains or 0.57 (0.13–2.56)
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Telephone interviews were used to ascertain symptoms and home characteristics; indoor allergens (house dust mites, cockroaches, cats, and dogs) , airborne fungal spores, and NO2 were measured.
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• There is sufficient evidence of an association between the presence of "mold" (otherwise unspecified) in a damp indoor environment and cough.
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From page 202... ...
Data on four measures of household dampness were analyzed: household water damage, visible mold, water in the basement, and wall or window dampness. Reported household water damage was associated with an OR greater than 1.0 for current wheezing (1.7; 0.9–3.0)
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From page 203... ...
Brunekreef, 1992 2,685 parents of Self-reported damp stains or 1.43 (1.15–1.77) children 6–12 years old mold growth (last 2 years)
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years old) cohort Visible mold on indoor 2.4 (1.4–4.3)
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From page 205... ...
Park et al., 2001 499 infants with at least Family-room dust endotoxin 1.33 (0.99–1.79) one parent with asthma ≥ 100 EU/mg for any wheeze or allergy 1.55 (1.00–2.42)
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From page 206... ...
Jaakkola et al., 1993 2,568 preschool Self-reported moldy odor in 4.31 (1.61–11.6) for children preceding year persistent wheeze Self-reported water damage 8.67 (3.87–19.4)
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From page 207... ...
mold Self-reported damp stains and 1.54 (0.59–4.00) mold Strachan et al., 1990 1,000 children (7 years old)
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From page 208... ...
. • There is inadequate or insufficient evidence to determine whether an association exists between the presence of mold or other agents in damp indoor environments and episodes of dyspnea (shortness of breath)
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cohort 2.7 (1.3–5.4) nocturnal Visible mold on indoor 2.2 (1.2–4.0)
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From page 210... ...
. The clinical syndromes that result from the presence of fungi in the paranasal sinuses include acute invasive fungal sinusitis, chronic invasive fungal sinusitis, mycetoma, and allergic fungal sinusitis.
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From page 211... ...
As noted above, fungal colonization is often found in the sinuses of both healthy persons and those who have sinusitis or nasal symptoms. Available information does not indicate that exposure to a damp indoor environment or the presence of agents associated with them places otherwise-healthy people at risk for the various forms of sinusitis.
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From page 212... ...
The following conclusions apply to persons who do not suffer from those diseases, which are addressed separately in this chapter: • There is inadequate or insufficient evidence to determine whether an association exists between exposure to a damp indoor environment and airflow obstruction in otherwise healthy people. • There is inadequate or insufficient evidence to determine whether an association exists between the presence of mold or other agents in damp indoor environments and airflow obstruction in otherwise healthy people.
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From page 213... ...
Little attention has been paid to it as a health outcome possibly associated with nonagricultural indoor exposure to microbial agents. The committee concludes that there is inadequate or insufficient information to determine whether an association exists between indoor dampness or dampness-related agents and mucous membrane irritation syndrome.
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From page 214... ...
However, there is inadequate or insufficient information to determine whether an association exists between indoor dampness or dampness-related agents and chronic obstructive pulmonary disease itself. Symptoms experienced by those diagnosed with COPD are addressed in the section titled "Respiratory Symptoms" earlier in the chapter.
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From page 215... ...
Objective information about the presence and severity of asthma can be obtained by demonstrating airflow obstruction with spirometry. Alternatively, evidence of airflow obstruction can be obtained by measuring peak expiratory flow.
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From page 216... ...
Most studies that focus specifically on fungal sensitivity also use only a few extracts, Alternaria again being the dominant type. A 2002 study of IgG and IgE antibodies in Finnish children who attended a water-damaged school found that the number of positive IgG antibodies did not correlate with respiratory symptoms or illnesses although the mean number of positive IgG findings was higher in the exposed group (Savilahti et al., 2002)
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From page 217... ...
The nature of the gene-environment interactions relevant to damp indoor environments is a topic of a great deal of research and is not completely understood. For example, studies about genetic susceptibility to the inflammatory effects of endotoxin are yielding interesting findings, but no firm conclusions can yet be drawn that can be applied directly to the issue of endotoxin exposure in damp indoor spaces (Vercelli, 2003)
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From page 218... ...
Conclusions regarding microbial agents that are addressed in the present report are omitted from the table. Some investigators have examined the association between self-reports of asthma symptoms in people who identify themselves as asthmatic and their presence in damp or moldy indoor environments.
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From page 219... ...
Inadequate or Insufficient Evidence to Determine Whether an Association Exists Cow and horse Pesticides Rodents (as pets or feral animals) Plasticizers Chlamydia trachomatis Houseplants Pollen exposure in indoor environments Insects other than cockroaches Limited or Suggestive Evidence of No Association (no agents met this definition)
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From page 220... ...
for damp stains, water damage "current asthma symptoms" Engvall et at., 2001 3,241 persons randomly At least one sign of dampness 2.28 (2.19–2.37) sampled in multi-family for "asthma symptoms" buildings At least one dampness-related 2.38 (2.30–2.47)
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From page 221... ...
1989 164 women Self-reported damp homes 4.16 (p<0.05) Case-Control Studies Norbäck et al., 1999 98 cases and 357 Self-reported water damage or 1.9 (1.2–2.9)
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TABLE 5-6 continued 222 Reference Subjects Dampness or Mold Measure Risk Estimate Williamson et al., 1997 102 asthmatics; 196 Self-reported dampness or 1.93(1.14–3.28) , matched controls (5–44 condensation in present home physician-diagnosed years old)
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From page 223... ...
, children (3–15 years physician confirmed old) asthma Jaakkola et al., 1993 2,568 preschool Self-reported water damage 2.52 (0.93–6.870 children >1 year ago Self-reported mold odor in last 1.46 (0.34–6.29)
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From page 224... ...
(5–8 years old) visible mold Mohamed et al., 1995 77 child cases and 77 Author-observed damp damage 4.9 (2.0–11.7)
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From page 225... ...
and visible mold and an OR of 1.66 (1.25–2.19) between "current asthma" and visible mold, damp stains, or water damage.
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From page 226... ...
Conclusions regarding microbial agents that are addressed in the present report are omitted from the table. Studies of damp indoor environments or dampness-related agents and asthma development are summarized in Table 5-8.
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From page 227... ...
Respiratory syncytial virus (RSV) Inadequate or Insufficient Evidence to Determine Whether an Association Exists Cat NO 2, NOx Cow and horse Pesticides Dog Plasticizers Domestic birds Formaldehyde Rodents Fragrances Cockroaches (except for preschool-age ETS (in school-age and older children)
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From page 228... ...
0.91 (0.60–1.39) Visible mold or odor 0.98 (0.68–1.40)
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From page 229... ...
(1998) examined the influence of indoor environmental factors on the development of asthma in children 3–15 years old.
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From page 230... ...
(No other mold was found in enough households to allow separate analysis; the "other mold" spore count was determined by subtracting Penicillium and Cladosporium from the total.) They found an association between higher Penicillium concentrations and greater incidence of wheeze and persistent cough (p < 0.05 for trend)
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From page 231... ...
• There is inadequate or insufficient evidence to determine whether an association exists between the presence of mold or other agents in damp indoor environments and the development of asthma. The exposure-assessment problems in the papers examined and the small number of longitudinal studies performed limit the confidence that can be placed in their results.
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From page 232... ...
. It is not uncommon for building-related illness to occur when, despite careful investigation, it is not clear whether the respiratory illness observed is HP or another clinical syndrome that is not yet defined (Trout et al., 2001)
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From page 233... ...
It has thus been studied with relation to specific agents rather than dampness in general. Studies reviewed by the committee indicate that there is sufficient evidence of an association between the presence of mold and bacteria in damp indoor environments and hypersensitivity pneumonitis in such people.
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From page 234... ...
. Although concentrations of organic dust consistent with the development of ODTS are very unlikely to be found in homes or public buildings, clinicians should consider the syndrome as a possible explanation of symptoms experienced by some occupants of highly contaminated indoor environments.
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From page 235... ...
Not all forms of immune compromise are the same: the susceptibility of hosts to different fungal infections or other fungal processes depends on the nature of their deficit. Further, fungal infections experienced by immune-compromised persons do not always involve genera and species that are typically associated with damp indoor environments.
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From page 236... ...
Otherwise-Healthy Persons A few studies have examined the association of the presence of fungi or other agents in damp indoor spaces with respiratory infections or illnesses in otherwise-healthy children. Comparable studies of adults were not identified.
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From page 237... ...
Healthy persons exposed to damp or moldy indoor environments sometimes report that they are more prone to respiratory infections, including the common cold, sinusitis, tonsillitis, otitis, and bronchitis. Some investigators have suggested that could be due to an immunosuppressive effect (Johanning et al., 1996)
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From page 238... ...
• There is inadequate or insufficient evidence to determine whether an association exists between exposure to dampness or the presence of mold or other agents in damp indoor environments and respiratory illness in otherwise-healthy adults. Pulmonary Hemorrhage or Hemosiderosis Pulmonary hemorrhage or hemosiderosis is a pathologic condition characterized by an abnormal accumulation of hemosiderin, an iron-containing pigment, in lung tissue (Boat, 1998)
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From page 239... ...
At autopsy, hemosiderin-laden macrophages may be found in lung tissue at the site of bleeding. Overview of the Evidence Investigators described eight cases of acute pulmonary hemorrhage or hemosiderosis in infants presenting at a Cleveland children's hospital in 1993–1994 (CDC, 1994)
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From page 240... ...
In 1997, CDC convened an internal scientific taskforce and a panel of outside experts was chosen to review the possible association between pulmonary hemorrhage/hemosiderosis in infants and S chartarum in the indoor environment (CDC External Expert Panel, 1999; CDC Working Group, 1999)
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From page 241... ...
. However, the editorial note that accompanied the 2000 CDC report was highly critical of the original findings in the 1997 report and advised that conclusions regarding the possible association between cases of pulmonary hemorrhage/hemosiderosis in infants in Cleveland and household water damage or exposure to S
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From page 242... ...
The committee concludes that available case-report information, taken together, constitutes inadequate or insufficient information to determine whether an association exists between AIPHI and the presence of Stachybotrys chartarum or agents present in damp indoor spaces in general. AIPHI is a serious health outcome, and the committee encourages the CDC to pursue surveillance and additional research on the issue to resolve outstanding questions.
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From page 243... ...
The committee's judgment about the association between exposure to damp indoor spaces or the presence of mold or other agents in damp indoor environments and these health outcomes is discussed at the end of the section. Skin It is well established that severely immunocompromised patients -- for example, those treated with immunosuppressive drugs during transplantation procedures, cancer patients receiving chemotherapy, AIDS patients -- can develop opportunistic cutaneous and subcutaneous fungal infections of the skin (Wald et al., 1997)
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From page 244... ...
mold, damp stains, for atopic dermatitis or water damage Koskinen 699 adults (16+ Surveyor-assessed 1.03 (0.71–1.49) et al., 1999a years old)
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From page 245... ...
Nausea, vomiting, and diarrhea are sometimes reported by persons exposed to dampness and molds in indoor spaces (Dales et al., 1991a) , but relatively few epidemiologic studies have evaluated the association between these symptoms and damp indoor conditions.
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From page 246... ...
et al., 1989 homes for nausea, vomiting Table 5-11 summaries the results of studies of people in damp and moldy environments in which fatigue was examined. As evidenced by rather broad confidence intervals, data on relatively small numbers of people were analyzed in some of the studies.
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From page 247... ...
Stachybotrys chartarum and Aspergillus spp. were identified on moisture-damaged interior surfaces and in air samples taken in these structures.
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From page 248... ...
248 TABLE 5-11 Selected Epidemiologic Studies -- Fatigue and Related Symptoms and Exposure to Damp Indoor Environment or Presence of Mold or Other Agents in Damp Indoor Environments Reference Subjects Dampness or Mold Measure Risk Estimate Cross-sectional studies Engvall et al., 2002 3,241 adults Self-reported odor and water 2.54 (2.38–2.71) leakage in last 5 years for tiredness Lander et al., 2001 86 workers in moist Histamine-release test (HRT)
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From page 249... ...
for fatigue Self-reported water damage 1.99 (1.35–2.92) for fatigue Pirhonen et al., 1996 1,460 adults Self-reported damp or mold 1.81 (1.37–2.39)
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From page 250... ...
The committee did not identify any peerreviewed scientific literature that addressed microbial agents found indoors and the inhalation route of exposure. A 2002 study showed that human
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From page 251... ...
There is some evidence that cold, damp indoor spaces causes erythematous skin lesions known as chilblain lupus erythematosus of Hutchinson, but there is little evidence that this problem is associated with systemic lupus erythematosus (Franceschini et al., 1999)
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From page 252... ...
The association between fungal exposures and opportunistic fungal infections of the skin of severely immunocompromised persons is well established. For all the other listed outcomes, the committee concludes that there is inadequate or insufficient information to determine whether an association exists between them and exposure to a damp indoor environment or the presence of mold or other agents associated with damp indoor environments.
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From page 253... ...
Skin symptoms Mucous membrane irritation syndrome Gastrointestinal tract problems Chronic obstructive pulmonary disease Fatigue Inhalation fevers (nonoccupational exposures) Neuropsychiatric symptoms Lower respiratory illness in otherwise-healthy adults Cancer Acute idiopathic pulmonary hemorrhage in infants Reproductive effects Rheumatologic and other immune diseases aThese conclusions are not applicable to immunocompromised persons, who are at increased risk for fungal colonization or opportunistic infections.
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From page 254... ...
Asthma development Mucous membrane irritation syndrome Gastrointestinal tract problems Chronic obstructive pulmonary disease Fatigue Inhalation fevers (nonoccupational exposures) Neuropsychiatric symptoms Lower respiratory illness in otherwise-healthy adults Cancer Rheumatologic and other immune diseases Reproductive effects Acute idiopathic pulmonary hemorrhage in infants aThese conclusions are not applicable to immunocompromised persons, who are at increased risk for fungal colonization or opportunistic infections.
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From page 255... ...
Epidemiologic and case studies should take a broad-based approach to gathering and evaluating information on exposures and other factors that would help to elucidate the etiology of acute pulmonary hemorrhage or hemosiderosis in infants, including dampness and agents associated with damp indoor environments; ETS and other potentially adverse exposures; and social and cultural circumstances, race/ethnicity, housing conditions, and other determinants of study subjects' health. • Concentrations of organic dust consistent with the development of organic dust toxic syndrome are very unlikely to be found in homes or public buildings.
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From page 256... ...
1998. Pulmonary Hemorrhage and Hemoptysis.
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From page 257... ...
:494–495. CDC External Expert Panel (CDC External Expert Panel on Acute Idiopathic Pulmonary Hemorrhage in Infants)
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From page 258... ...
American Journal of Respiratory and Critical Care Medicine 164(1)
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From page 259... ...
American Journal of Respiratory and Critical Care Medicine 166(7)
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From page 260... ...
1993. Childhood asthma and indoor environmental risk factors.
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From page 261... ...
1995. American Journal of Respiratory and Critical Care Medicine 151(6)
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From page 262... ...
1997. Environmental risk factors associated with pediatric idiopathic pulmonary hemorrhage and hemosiderosis in a Cleveland community.
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From page 263... ...
American Journal of Respiratory and Critical Care Medi cine 157:410–414. Nagda NL, Hodgson M
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From page 264... ...
2000. Guidelines on Assessment and Remediation of Fungi in Indoor Environments.
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From page 265... ...
-β-D-glucan exposure in two schools. American Journal of Respiratory and Critical Care Medicine 158:1685–1687.
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American Journal of Respiratory and Critical Care Medicine 163(7)
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From page 267... ...
American Journal of Respiratory and Critical Care Medicine 157(6 Pt 1)
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From page 268... ...
American Journal of Respiratory and Critical Care Medicine 167(11)
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1998. Indoor environmental risk factors and childhood asthma: a case-control study in a subtropical area.
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