Mold in the Richmond Veterans Hospital

According to the Institute of Medicine of the Center for Disease Control and Prevention (CDC) there is sufficient evidence to link indoor exposure to mold with upper respiratory tract symptoms, cough, and wheeze in otherwise healthy people; with asthma symptoms in people with asthma; and with hypersensitivity pneumonitis in people with stressed or compromised immune systems. In addition there is evidence linking indoor mold exposure and respiratory illness. While molds are present at low levels in air, a mold problem in any building can be unpleasant or even sickening to the occupants, but as will be shown below, exposing hospital patients to a “moldy” environment can increase the risk of infection in some patients and therefore requires rigorous remediation.

Last March the McGuire Veterans Administration Medical Center in Richmond, Virginia hired an environmental consulting firm to perform an Indoor Air Quality Assessment in response to complaints from employees and patients about perceive poor indoor air quality and a recommendation from an outside group. The consultants performed a visual assessment of wards 1U, 1V and 1W and the Nurses Stations, checked the filters in the HVAC systems and made sure that the HVAC systems appeared to be clean. They also recorded the Temperature, Relative Humidity, Carbon Monoxide and Carbon Dioxide and used the test device called Micro 5 five minute low volume spore traps to collect 14 interior hallway samples and one exterior sample to measure total airborne fungal spore levels at a particular point in time in an attempt to identify if the hospital had a mold problem that might be impacting the employees and patients.

Currently, there are no federal standards (OSHA, NIOSH, EPA or CDC) for airborne concentrations of mold or mold spores.There are however OSHA , EPA and CDC guidlines for mold remediation wich implicity acknowledges the seriousness of mold contamination. Scientific research on the relationship between mold exposures and health effects continues, but there are yet to be determined absolute levels of exposure that are of no concern and threshold numeric levels likely to impact exposed populations. Molds are part of the natural environment. Molds are fungi that can be found anywhere - inside or outside all year long. About 1,000 species of mold can be found in the United States, with more than 100,000 known species worldwide. In recent years indoor air quality experts, the World Health Organization (WHO), Industrial hygienists and several scientific groups have developed standard approaches to investigating mold problems. Spore traps have become the dominant way of airborne mold sampling, but only test for a handful of spore species that most commonly indicate a problem.

There have been recent papers, presentations, and scientific articles that address whether an interior space is “moldy.” What emerges from these evaluations is that the most common indicator of mold problems in a damp environment is the elevated presence of two related species in particular Aspergillus/Penicillium. These spores are the primary colonizers according to the World Health Organization (WHO – 2009) and often amplify in the indoor environment in response to increased moisture. In addition, it is well documented in studies funded by the National Institute of Health that elevated concentrations of Aspergillus species of fungus in critical-care areas of hospitals, may result in an increased risk of infection in immuno-compromised patients (Kordbacheh et al. 2005; Lee et al. 2007). The CDC states that “the types of health problems caused by Aspergillus include allergic reactions, lung infections, and infections in other organs.” Thus, in the chart below and the discussion that follows, I only examine Aspergillus/Penicillium and total spore count in the 15 samples taken to determine if the sampling results are indicative of a mold problem at the McGuire VA Medical Center in Richmond, VA.

When evaluating fungal spore levels there are three basic approaches to determine if the spore levels measured in a spore trap are of concern: comparing the finding to a reference sample, typically outdoor sample is taken, comparing the value to a control sample from similar building(s) that has not been impacted, or comparing the findings against a data base of mold impacted buildings.

When doing a spore trap sampling it is common with residential and small commercial investigations to sample the outdoor air as a reference sample as was done in this instance. However, air residence time in larger buildings can be hours or several days depending on the size of the building and air flow circulation and whether air filtration systems are operating. In modern buildings with active mechanical ventilation systems the indoor concentration of airborne spore is generally expected to be between 20-70% of the outdoor concentration with an assumed average of 50%. It is important to note that the comparison should be the relative concentration of each spore type and not just the total spore concentration (Spurgeon, 2004). As you can see in the chart above only one sample location (1W-103) had an Aspergillus/Penicillium spore count within the expected range compared to the exterior, all of the other samples were 100% to 2,950%. For the total spore count only the samples with the highest levels of Aspergillus/Penicillium (1U-141 and 1U-138) exceeded the expected range. By comparison to an exterior (reference) sample elevated levels of Aspergillus/Penicillium spores are of concern.

In large commercial complexes control samples can often be obtained from unimpacted buildings or unimpacted wings of buildings. Though the total spore count in most of the samples is significantly below the exterior sample, the elevated levels of Aspergillus/Penicillium and two samples showing elevated total spore levels indicate that there are areas within the building that are more impacted by fungal spores than others. The data indicates a hot spot that is more significantly impacted than other areas, though elevated levels of Aspergillus/Penicillium are ubiquitous. These hot spots should be more fully delineated. Remediation of the area should take place after identifying and eliminating the sources of moisture.

The final method of evaluating fungal spore data is by comparing the samples taken to a database of sampling results for buildings that have been tested. The concentration of airborne contaminants can be characterized by a lognormal distribution with a geometric mean concentration and standard deviation. Joe Spurgeon, PhD, CIH performed an analysis on the data from three studies to find the Aspergillus/Penicillium level for a “moldy” environment. Dr. Spurgeon created the table below from three separate groups of data:

Aspergillus/Penicillium levels considered as indicative of a “moldy” environment from three independent studies:

1. Baxter data: Asp/Pen ≥ 950 spores/m3
2. Rimkus data: Asp/Pen ≥1,000 spores/m3
3. Spurgeon data: Asp/Pen ≥ 1,000‐1,100 spores/m3

The sample from 1U-141 location would be classified by this database comparative approach as a moldy environment. In addition, that sample was in the 95-99 percentile for Aspergillus/Penicillium compared to all building samples represented in the database. Clearly the extent and source of the Aspergillus/Penicillium fungal spores needs to be identified, isolated and remediated.

In all methods of evaluation, the levels of Aspergillus/Penicillium identified at the McGuire VA Medical Center indicate a localized but significant mold problem that might impact the health of patients and staff. Additional tests should be performed to delineate the extent of the problem. The area of impact should be remediated following U.S. EPA and the CDC guidelines and confirmation testing performed. It is my understanding that the on-site Administrator has chosen to take no action, but this could potentially impact the health and comfort of the staff and our most vulnerable patients.

While there are currently no  federal regulations setting a threshold level for mold concentrations that would require remediation, available research shows that such a level is already and increasingly knowable. It is only a matter of time until such knowledge is embodied in a regulation and it is better to act now on what we already now then to risk harm while awaiting regulation to force action. We have established the Veterans Administration hospital system especially for veterans due to their extraordinary service to our county and a problem like this which puts their heath at further risk should not be ignored. In Pittsburgh, PA hospital patients died of mold infections. 

Stay Dry- Avoid Mold

Mold is a thought that strikes fear in my heart, but not for the reasons you think. I monitored the mold research for several years before I retired and watched as the concern for severe health impacts receded. The fear that engulfed the topic in 2001 seemed to engage the nation as evidenced by the New York Times Magazine cover story “Haunted By Mold” by Lisa Belkin telling the tragic story of uncontrolled mold in Texas and the California Toxic Mold Protection Act of 2001 (SB 732) that has since been abandoned for lack of scientific evidence. Research could not correlate health impacts to mold exposure levels. My fear of mold is based on their favorite food, paper, and the more than 20,000 books that reside in my basement. Of course in protecting the books I am protecting myself since I have for years suffered from mold allergies a condition that is well accepted by scientists and health professionals.

Molds are neither plant nor animal, but fungi that can be found almost anywhere; they can grow on virtually any organic substance, as long as moisture and oxygen are present. Wet cellulose materials, including paper and paper products, (books, books and more books), cardboard, ceiling tiles, wood, and wood products, are particularly conducive for the growth of many types of molds. Molds grow by digesting and destroying these organic material. Many other materials in your home such as paints, tile grout, wallpaper, insulation, drywall, carpet, shower curtains, window shades, and upholstery, also serve as excellent locations for mold growth. Indoor molds are ubiquitous, but are not usually a problem unless there is a moisture problem.

The most common indoor molds are Cladosporium, Penicillium, Aspergillus, and Alternaria. However, Stachybotrys chartarum is a greenish-black cellulose loving mold that has gotten a tremendous amount of attention as the “toxic mold” of 2001 fame. That term is not accurate. While certain molds can produce mycotoxins, and are thus are toxigenic, the molds themselves are not toxic, or poisonous. After much research, the US Environmental Protection Agency (EPA) and the US Center for Disease Control and Prevention (CDC) and the California Department of Health Services (CDPH) and the public health community at large agree that allergic reactions to mold in buildings occur, particularly for sensitized persons. However, in the present peer-reviewed medical literature, there is no conclusive evidence that mold toxins in buildings cause any human health illness. Though there are case reports of symptoms caused by mold toxins; evidence is inconclusive. Breathing in mold or other dampness related bacteria may cause hypersensitivity pneumonitis, an uncommon disease that resembles bacterial pneumonia. In addition, mold exposure may result in opportunistic infections in persons whose immune systems are weakened or suppressed, have existing lung disease, or asthma.

After considerable research into this issue, scientists and the World Health Organization concluded in October 2006 that although recent studies have strengthened the evidence between living and/or working in a damp environment and increased risk for respiratory symptoms, the role of mold growth in these complex environments is still unclear. Damp buildings also encourage the growth of bacteria, dust mites and cockroaches, as well as degradation of wet building materials that can also release irritant chemicals indoors. Some or all of these chemicals or biological organisms may contribute to occupant illness. Thus, science based exposure limits for indoor molds cannot be established at this time. However, the presence and health risks of biological contaminants in indoor air are all caused by moisture which should be prevented or stopped as soon as possible.

In summary, Stachybotrys chartarum (Stachybotrys atra) and other molds may cause health symptoms that are nonspecific. At present there is no scientific evidence that proves a cause and effect relationship between Stachybotrys chartarum and a particular health symptom or condition. Reliable sampling for mold can be expensive, and standards for judging the level of mold exposure that is not acceptable or cannot be safely tolerated have not been established. So testing for any particular type of mold is a waste of money. It is not necessary to identify the species of mold growing in a residence, and CDC does not recommend routine sampling for molds. Currently, there is no air sampling or environmental test that can determine if mold found in buildings is producing toxins, nor can any blood or urine test establish that an individual has been exposed to Stachybotrys chartarum spores or toxins. To the susceptible population any mold that is seen or smelled is a potential health risk; therefore, no matter what type of mold is present, you should remediate the problem beginning with solving the moisture problem.

Molds can multiply by producing microscopic spores (2 - 100 microns in diameter) that easily float through window screens, attach to clothing or pets or is pulled into a home through a fresh air ducts. Mold spores are ubiquitous, but are not usually a problem inside a home unless there is a moisture problem. Molds only grow when there is moisture from water damage, excessive humidity, water leaks, condensation, water infiltration, or flooding. Constant moisture is required for mold to grow. Thus, your first defense against mold is keeping moisture out. As part of routine building maintenance, buildings should be inspected for evidence of water infiltration in ceiling or walls, water stains from small leaks, water damage around windows and doors, indications of small plumbing or other water leaks and visible mold. The conditions causing mold (such as water leaks, condensation, infiltration, or flooding) should be corrected to prevent mold from growing.

Well-designed, well-constructed, well-maintained building envelopes are essential to prevent and control moisture and microbial growth. Management of moisture requires proper control of temperature and ventilation to avoid excess humidity, condensation on surfaces and excess moisture. Ventilation should be distributed effectively throughout spaces. Specific Recommendations:

• Inspect your home for signs of moisture.
• Keep humidity level in house between 40% and 60%.
• Use air conditioner or a dehumidifier during humid months.
• Be sure the home has adequate ventilation, including exhaust fans in kitchen and bathrooms.
• Fix leaky plumbing, roof leaks and basement water infiltration as soon as possible.
• Dry wet or damp areas within 24-48 hours.
• Keep heating and air conditioning drip plans clean and flowing.
• Perform regular heating and air conditioning inspections to identify problems early.
• Use mold inhibitors which can be added to paints.
• Clean bathroom with mold-killing products.
• Do not carpet bathrooms.
• Remove and replace flooded carpets.
• Do not let foundations stay wet.
• Provide drainage and slope the ground away from the foundation.