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Damp Indoor Spaces
A N D H E A LT H
Committee on Damp Indoor Spaces and Health
Board on Health Promotion and Disease Prevention
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THE NATIONAL ACADEMIES PRESS 500 Fifth Street, NW Washington, DC 20001
NOTICE: The project that is the subject of this report was approved by the Govern-
ing Board of the National Research Council, whose members are drawn from the
councils of the National Academy of Sciences, the National Academy of Engineer-
ing, and the Institute of Medicine. The members of the committee responsible for the
report were chosen for their special competences and with regard for appropriate
balance.
This study was supported by Contract No. 200-2000-0629, TO #08 between the
National Academy of Sciences and Centers for Disease Control and Prevention. Any
opinions, findings, conclusions, or recommendations expressed in this publication
are those of the author(s) and do not necessarily reflect the view of the organizations
or agencies that provided support for this project.
Library of Congress Cataloging-in-Publication Data
Institute of Medicine (U.S.). Committee on Damp Indoor Spaces and Health.
Damp indoor spaces and health / Committee on Damp Indoor Spaces and Health,
Board on Health Promotion and Disease Prevention.
p. ; cm.
Includes bibliographical references and index.
ISBN 0-309-09193-4 (hardback)
1. Indoor air pollution—Health aspects. 2. Dampness in buildings—Health
aspects. 3. Air—Microbiology—Health aspects. 4. Housing and health.
[DNLM: 1. Air Pollution, Indoor—adverse effects. 2. Air Pollution, Indoor—
prevention & control. 3. Air Microbiology. 4. Bacterial Toxins—adverse effects.
5. Mycotoxins—adverse effects. 6. Respiratory Tract Diseases—epidemiology.
WA 754 I5538 2004] I. Title.
RA577.5.I565 2004
613'.5—dc22
2004014365
Additional copies of this report are available for sale from the National Academies
Press, 500 Fifth Street, NW, Lockbox 285, Washington, DC 20055; call (800) 624-
6242 or (202) 334-3313 (in the Washington metropolitan area); Internet, http://
www.nap.edu.
For more information about the Institute of Medicine, visit the IOM home page at:
www.iom.edu.
Copyright 2004 by the National Academy of Sciences. All rights reserved.
Printed in the United States of America.
The serpent has been a symbol of long life, healing, and knowledge among almost all
cultures and religions since the beginning of recorded history. The serpent adopted
as a logotype by the Institute of Medicine is a relief carving from ancient Greece,
now held by the Staatliche Museen in Berlin.
Cover: The images for the cover design were provided by Terry Brennan. The image
at the center of the design is Stachybotrys chartarum and the border image is Cla-
dosporium on paint.
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“Knowing is not enough; we must apply.
Willing is not enough; we must do.”
—Goethe
Adviser to the Nation to Improve Health
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The National Academy of Sciences is a private, nonprofit, self-perpetuating society
of distinguished scholars engaged in scientific and engineering research, dedicated to
the furtherance of science and technology and to their use for the general welfare.
Upon the authority of the charter granted to it by the Congress in 1863, the Acad-
emy has a mandate that requires it to advise the federal government on scientific and
technical matters. Dr. Bruce M. Alberts is president of the National Academy of
Sciences.
The National Academy of Engineering was established in 1964, under the charter of
the National Academy of Sciences, as a parallel organization of outstanding engi-
neers. It is autonomous in its administration and in the selection of its members,
sharing with the National Academy of Sciences the responsibility for advising the
federal government. The National Academy of Engineering also sponsors engineer-
ing programs aimed at meeting national needs, encourages education and research,
and recognizes the superior achievements of engineers. Dr. Wm. A. Wulf is president
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The Institute of Medicine was established in 1970 by the National Academy of Sci-
ences to secure the services of eminent members of appropriate professions in the
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The National Research Council was organized by the National Academy of Sciences
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Alberts and Dr. Wm. A. Wulf are chair and vice chair, respectively, of the National
Research Council.
www.national-academies.org
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COMMITTEE ON DAMP INDOOR SPACES AND HEALTH
Noreen M. Clark, PhD (Chair), Dean, Marshall H. Becker Professor of
Public Health, and Professor of Pediatrics, University of Michigan,
Ann Arbor, Michigan
Harriet M. Ammann, PhD, DABT, Senior Toxicologist, Air Quality
Program, Washington State Department of Ecology, Olympia,
Washington
Bert Brunekreef, PhD, Professor of Environmental Epidemiology, Institute
of Risk Assessment Sciences, University of Utrecht, The Netherlands
Peyton Eggleston, MD, Professor of Pediatrics and Professor of
Environment Health Sciences, Johns Hopkins University, Baltimore,
Maryland
William J. Fisk, MS, PE, Senior Staff Scientist and Department Head,
Indoor Environment Department, Lawrence Berkeley National
Laboratory, Berkeley, California
Robert E. Fullilove, EdD, Associate Dean for Community and Minority
Affairs, Columbia University School of Public Health, New York,
New York
Judith Guernsey, MSc, PhD, Associate Professor, Department of
Community Health and Epidemiology, Dalhousie University, Halifax,
Nova Scotia, Canada
Aino Nevalainen, PhD, Head of Laboratory, Division of Environmental
Health, National Public Health Institute (KTL), Kuopio, Finland
Susanna G. Von Essen, MD, Professor of Pulmonary and Critical Care
Medicine, University of Nebraska Medical Center at Omaha,
Nebraska
Consultants to the Committee
Terry Brennan, MS, President, Camroden Associates, Inc., Westmoreland,
New York
Jeroen Douwes, PhD, Associate Director, Centre for Public Health
Research, Massey University, Wellington, New Zealand
Staff
David A. Butler, PhD, Study Director
Jennifer A. Cohen, Research Associate
Joe A. Esparza, Senior Project Assistant
Elizabeth J. Albrigo, Project Assistant
Norman Grossblatt, Senior Editor
Rose Marie Martinez, ScD, Director, Board on Health Promotion and
Disease Prevention
v
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Reviewers
This report has been reviewed in draft form by persons chosen for their
diverse perspectives and technical expertise, in accordance with procedures
approved by the National Research Council’s Report Review Committee.
The purpose of this independent review is to provide candid and critical
comments that will assist the institution in making its published report as
sound as possible and to ensure that the report meets institutional standards
of objectivity, evidence, and responsiveness to the study charge. The review
comments and draft manuscript remain confidential to protect the integrity
of the deliberative process. We wish to thank the following for their review
of this report:
Diane R. Gold, MD, MPH, Harvard Medical School and Harvard School
of Public Health
William B. Rose, MArch, School of Architecture, University of Illinois at
Urbana-Champaign
Jonathan M. Samet, MD, Bloomberg School of Public Health, Johns
Hopkins University
Richard J. Shaughnessy, PhD, Indoor Air Program, University of Tulsa
Linda D. Stetzenbach, PhD, Harry Reid Center for Environmental Studies,
University of Nevada, Las Vegas
Mark J. Utell, MD, University of Rochester School of Medicine and
Dentistry
Although the reviewers listed above have provided many constructive
comments and suggestions, they were not asked to endorse the conclusions
or recommendations, nor did they see the final draft of the report before its
release. The review of this report was overseen by Robert B. Wallace, MD,
University of Iowa, and John C. Bailar III, MD, PhD, University of Chicago.
Appointed by the National Research Council and Institute of Medicine, they
were responsible for making certain that an independent examination of
this report was carried out in accordance with institutional procedures and
that all review comments were carefully considered. Responsibility for the
final content of this report rests entirely with the authoring committee and
the institution.
vi
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Acknowledgments
This report could not have been prepared without the guidance and ex-
pertise of numerous persons. Although it is not possible to mention by name
all those who contributed to the committee’s work, the committee wants to
express its gratitude to a number of them for their special contributions.
Sincere thanks go to all the participants at the workshops convened
on March 26, June 17, and October 8, 2002. The intent of the workshops
was to gather information regarding issues related to damp indoor spaces,
health effects attributed to microbial agents found indoors, and mold- and
moisture-related research. The speakers, who are listed in Appendix A, gave
generously of their time and expertise to help inform and guide the com-
mittee’s work.
We are deeply indebted to two hard-working people—Terry Brennan
and Jeroen Douwes—who served as consultants and made major contribu-
tions to the content of this report. Special thanks are also extended to Harriet
Burge, chair of the committee from its inception through October 2002, for
her exceptional commitment and guidance during her tenure. The commit-
tee also thanks Ulla Haverinen-Shaughnessy and Anne Hyvärinen, who per-
mitted excerpting of text from their doctoral dissertations. Institute of Medi-
cine staff members Michelle Catlin, Ben Hamlin, and Michael Schneider
provided valuable input and help over the course of the study. The Commit-
tee on Damp Indoor Spaces and Health, of course, takes final responsibility
for all content in the report.
The committee extends special thanks to the dedicated and hard-work-
ing staff at the Institute of Medicine (IOM). The expertise and leadership of
Rose Marie Martinez, director of the IOM Board on Health Promotion and
Disease Prevention, helped to ensure that this report met the highest stan-
dards of quality.
Finally, the committee would like to thank the chair, Noreen Clark, for
her outstanding work, leadership, and dedication to this project.
vii
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viii
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Contents
EXECUTIVE SUMMARY 1
Framework and Organization, 2
The Committee’s Evaluation, 4
Reference, 16
1 BACKGROUND AND METHODOLOGIC CONSIDERATIONS 17
Intent and Goals of the Study, 17
Research Approach, 19
Evaluating the Epidemiologic Evidence, 21
Summarizing Conclusions Regarding Epidemiologic Evidence, 26
References, 27
2 DAMP BUILDINGS 29
Moisture Definitions, 30
Moisture Dynamics in Buildings—How Buildings Get Wet, 32
Prevalence, Severity, Location, and Duration of
Building Dampness, 44
Risk Factors for Moisture Problems, 51
From Moisture to Microbial Growth, 54
Microorganisms Occurring in Indoor Spaces and on
Building Materials, 56
Dampness-Related Problems Not Associated with Biologic Sources, 73
Summary, 75
Findings, Recommendations, and Research Needs, 76
References, 78
ix
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x CONTENTS
3 EXPOSURE ASSESSMENT 90
Introduction, 90
Definitions, 91
Sampling Strategies, 94
Assessing Microorganisms, 101
Assessing Microbial Constituents, 103
Assessing Bioallergens, 104
Indirect Exposure-Assessment Methods, 104
Concentrations in the Environment, 110
Evaluation of Exposure Data, 114
Findings, Recommendations, and Research Needs, 115
References, 116
4 TOXIC EFFECTS OF FUNGI AND BACTERIA 125
Considerations in Evaluating the Evidence, 126
Bioavailability and Route of Exposure, 126
Toxic Effects of Indoor Molds and Bacteria, 133
Findings, Recommendations, and Research Needs, 170
References, 171
5 HUMAN HEALTH EFFECTS ASSOCIATED WITH
DAMP INDOOR ENVIRONMENTS 183
Introduction, 183
Evaluating Health Effects, 186
Respiratory Symptoms, 189
Respiratory Tract Disorders, 208
Other Health Complaints and Disorders, 243
Findings, Recommendations, and Research Needs, 253
References, 255
6 PREVENTION AND REMEDIATION OF DAMP
INDOOR ENVIRONMENTS 270
Prevention, 270
Published Guidance for Mold Remediation, 271
Tasks Involved in Remediation, 284
Effects of Air and Surface Cleaning and Ventilation, 301
Findings, Recommendations, and Research Needs, 304
References, 306
7 THE PUBLIC HEALTH RESPONSE 311
Public Health and Housing, 312
Barriers to the Adoption of Dampness Prevention and
Reduction Measures, 313
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xi
CONTENTS
Public Health Approaches to Damp Indoor Environments, 314
Findings, Recommendations, and Research Needs, 327
References, 329
APPENDIXES
A WORKSHOP PRESENTATIONS AND SPEAKERS 333
B COMMITTEE, CONSULTANT, AND STAFF BIOGRAPHIES 336
INDEX 343
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