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7
The Public Health Response
Studies reviewed in this report indicate that:
· Dampness is prevalent in residential housing in a wide array of cli-
mates (Chapter 2);
· Sufficient evidence of an association exists between signs of damp-
ness and upper respiratory tract symptoms, cough, wheeze, and asthma
symptoms in sensitized persons (Chapter 5);
· Sufficient evidence of an association exists between signs of mold
and upper respiratory tract symptoms, cough, wheeze, asthma symptoms in
sensitized persons and hypersensitivity pneumonitis in susceptible persons
(Chapter 5).
The committee concludes, on the basis of this information and other find-
ings presented in Chapters 2 through 6, that excessive indoor dampness is a
public health problem.
This chapter draws together findings and recommendations presented
in earlier parts of the report and places them in the context of the mission of
public health to "[fulfill] society's interest in assuring conditions in which
people can be healthy" and its aim "to generate organized community
effort to address the public interest in health by applying scientific and
technical knowledge to prevent disease and promote health" (IOM, 1988).
It addresses the public health interest in housing, barriers to the adoption of
dampness prevention and reduction measures, and public health approaches
to addressing the problems created by damp indoor environments. The
311
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312 DAMP INDOOR SPACES AND HEALTH
chapter also operationalizes some of the findings, recommendations and
research needs presented in earlier chapters by suggesting specific actions
and actors to implement them.
PUBLIC HEALTH AND HOUSING
The influence of housing and the workplace on human health has long
been an element of public-health action and research (Susser, 1973). With
the industrialization of the United States, responsibility for workplace, hous-
ing, and public-health improvement efforts was clearly distinguished at the
local and national levels (Duffy, 1974; Galishoff, 1988; Melosi, 2000;
Rosner, 1995; Veiller, 1921). The sanitary-reform movement during the
1800s sought locally and federally to rectify the hazardous effects of over-
crowding, insufficient light and air, impure water, and the like associated
with inadequate housing. Similarly, the mechanisms through which hous-
ing promotes health or disease became the focus of considerable research
related to public health (Dedman et al., 2001; Dunn and Hayes, 2000;
Matte and Jacobs, 2000). The societal obligation to ensure safe and healthy
housing and workplaces has long been evident in building codes and zoning
policies, which, according to Freeman (2002), are
prima facie evidence that America has deemed a certain standard of hous-
ing a basic requirement of civilized society. If this were not so, we would
allow the poor and homeless to build shantytowns, as is done in many
cities of the Third World.
The environments in which we live and work, then, are widely accepted as
determinants of our health; and, as this report delineates, damp buildings
may pose a health risk.
Research also indicates that damp buildings have economic implica-
tions. Nguyen and colleagues (1998) examined direct costs (in inpatient
care, drugs, physicians, and nursing and clinic services) and indirect costs
(in lost work days and duration of disability) of asthma and other respira-
tory diseases associated with the presence of moisture and mold in resi-
dences in Finland. The authors estimated the cost of asthma associated with
moisture in buildings in 1996 at 137.5 million Finnish markkaa, which
translates to about U.S.$6.06 per person.1 The corresponding per capita
cost associated with mold in buildings was about U.S.$3.20. Such estimates
are necessarily based on simplifying assumptions and are subject to sub-
stantial uncertainty, but they highlight the fact that the effect of indoor
dampness on health has an economic dimension and that cost-effectiveness
1The calculation is based on a July 1996 population estimate of 5,105,230 and a January
1996 exchange rate of 4.4425 markkaa per U.S. dollar (CIA, 1997).
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THE PUBLIC HEALTH RESPONSE 313
studies are needed to assess the savings that damp-building prevention or
remediation might generate by reducing morbidity.
As noted in Chapter 2, dampness is more likely to be found in buildings
that are older, lack central heating, are poorly insulated (and hence subject
to cold and damp conditions), and are overcrowded. Buildings with those
characteristics are most evident in low-income communities (Krieger and
Higgins, 2002).
BARRIERS TO THE ADOPTION OF DAMPNESS PREVENTION
AND REDUCTION MEASURES
Chapter 6 identifies many technical measures and practices that could
prevent or reduce problematic indoor dampness. However, social and insti-
tutional barriers hinder their widespread adoption.
One important barrier is poverty. Historically, the distribution of poor
housing stock in the United States--as in many other nations--has been
largely associated with socioeconomic status (Evans and Kantrowitz, 2002)
and ethnicity (Lawrence and Martin, 2001). Ostensibly, the population at
greatest risk of exposure to dampness-related health problems in the United
States is the population that is the most poorly housed. Census statistics
indicate that the poor are more than three times as likely (22% versus 7%)
to have substandard-quality housing (Evans and Kantrowitz, 2002) and
that blacks and low-income people are more likely than the general popula-
tion to be in housing with severe physical problems (Krieger and Higgins,
2002).
Given the costs of maintaining a clean, dry, well-heated, and properly-
ventilated home, it should not be surprising that low-income families are
more likely to have substandard housing and to live in the kind of damp
interiors that may be associated with health problems. Children in such
families may bear an additional burden because they are more likely to be
in school buildings that have environmental problems: poor plumbing,
inadequate heating, and poor indoor air quality (Evans and Kantrowitz,
2002). Reviewing data accumulated in the second National Health and
Nutrition Examination Survey (NHANES II) and the Harvard Six Cities
Study, Eggleston (2000) concluded that ethnicity, poverty, and residence
combined to influence asthma prevalence in inner-city children in ways that
could not be easily disentangled.
Economic factors may encourage poor building practices. Combina-
tions of pressure to build quickly and cheaply can result in poorly con-
structed buildings that are more likely to have water leaks. Under ordinary
circumstances, the market works to sift out builders that produce shoddy
construction. However, in low-income neighborhoods--where options are
limited because there is a shortage of affordable housing--and in other
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314 DAMP INDOOR SPACES AND HEALTH
circumstances in which demand outstrips supply, the market may not pe-
nalize poor workmanship effectively (Parker, 1994).
Poverty combined with the lack of affordable housing may also create
incentives to forgo or limit investment in maintenance that might help to
prevent moisture problems. Landlords have little incentive to spend money
on repair when there is a surplus of people ready to accept any kind of low-
rent shelter (Ehrenreich, 2001). As already noted, those pressures also re-
sult in overcrowding, which can lead to excessive indoor moisture and
condensation problems (Markus, 1993), which in turn promote mold and
bacterial growth.
There are also other barriers to the implementation of dampness preven-
tion or reduction measures. The 2000 Institute of Medicine (IOM) report
Clearing the Air: Asthma and Indoor Air Exposures noted that "the relevant
features of building design, operation, and maintenance may be determined
substantially by speculative builders or other decision-makers who are sub-
stantially unaffected by future moisture problems" (IOM, 2000). Such mar-
ket imperfections isolate decision-makers from the consequences of their
choices and may thus lead to socially undesirable outcomes. Insufficient
awareness and training about dampness, its prevention, and its consequences
and the lack of a clear definition of the environmental conditions and prac-
tices that are harmful to health also hinder actions. The following pages
discuss those impediments and means of addressing them.
PUBLIC HEALTH APPROACHES TO
DAMP INDOOR ENVIRONMENTS
If excessive indoor dampness is a public health problem, then an appro-
priate public health goal should be to prevent or reduce the incidence of
potentially problematic damp indoor environments, that is, environments
that may be associated with undesirable health effects, particularly in vul-
nerable populations. However, there are serious challenges associated with
achieving that goal. As the literature reviewed in this report indicates, there
is insufficient information on which to base quantitative recommendations
for either the appropriate level of dampness reduction or the "safe" level of
exposure to dampness-related agents. The relationship between dampness
or particular dampness-related agents and health effects is sometimes un-
clear and in many cases indirect. Questions of exposure and dose have not,
by and large, been resolved (see Chapters 3 and 4). An additional challenge
is posed by the fact that it is not possible to objectively rank dampness-
related health problems within the larger context of threats to the public's
health. As the report notes, there is insufficient information available to
confidently quantify the overall magnitude of the risk resulting from expo-
sures in damp indoor environments. Even if those data were available, the
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THE PUBLIC HEALTH RESPONSE 315
choice of metric used for ranking--the number of illnesses or the cost of
lost work and school days, for example--would greatly influence the result.
What then can be done through public health mechanisms to prevent or
reduce the incidence of damp indoor environments? At least seven areas of
endeavor deserve discussion with relation to the agents and exposures ex-
amined in this report:2
· Assessment and monitoring of indoor environments at risk for prob-
lematic dampness.
· Modification of regulations, building codes, and building-related
contracts to promote healthy indoor environments; and enforcement of
existing rules.
· Creation of incentives to construct and maintain healthy indoor
environments.
· Development, dissemination, and implementation of guidelines for
the prevention of dampness-related problems.
· Public-health-oriented research and demonstration projects to evalu-
ate the short-term and long-term effectiveness of intervention strategies.
· Education and training of building occupants, health professionals,
and people involved in the design, construction, management, and mainte-
nance of buildings to improve efforts to avoid or reduce dampness and
dampness-related health risks.
· Collaborations among stakeholders to achieve healthier indoor
environments.
The separate areas are discussed in greater detail below.
Assessment and Monitoring
Although poor housing and health problems are especially evident in
low-income populations, the problems created by indoor dampness are by
no means limited to the homes of poor people, and they extend beyond
homes to workplaces, schools, and other commercial and public buildings.
If interventions are to be effective, an accepted first step is to establish
mechanisms for identifying existing or potential problems and their deter-
minants. At least one local health jurisdiction in the United States has
2A more general examination of housing and health is outside the scope of this report.
However, house dust mites, respiratory viruses, and cockroaches--all of which are associated
with damp conditions--may have an important effect on occupant health (IOM, 1993, 2000).
The literature also addresses how temperature acts as a contributory and independent risk
factor for increased morbidity and mortality in damp indoor environments, especially among
the elderly and poor (Evans et al., 2000; Healy, 2003; Mercer, 2003).
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316 DAMP INDOOR SPACES AND HEALTH
systematically collected and analyzed data on the adequacy of housing
(Marsh, 1982), but there appear to be few, if any, current population-
based, systematic efforts to identify and anticipate trouble spots (Krieger
and Higgins, 2002). Some general population surveys that include collec-
tion of data on dampness and specific dampness-related exposures have
been conducted.
Comprehensive data on the prevalence of dampness in residences are
collected as part of the biennial American Housing Survey (U.S. Census
Bureau, various years), which gathers information on the prevalence of
water leaks with outdoor and indoor sources. The number of households
surveyed has varied between roughly 88,000 and 106,000 over the years
19852001. Data indicate that over that time span there was little differ-
ence between the overall incidence of outdoor leaks and the incidence in
homes occupied by blacks, the elderly (65 years old or older) or those below
the poverty level. Leaks with indoor sources were more likely in homes
occupied by blacks and less likely in the homes of the elderly than in the
average home. It should be remembered that the data do not record how
able the occupants were to respond to instances of leakage--a major factor
in whether a particular incident becomes problematic.
As noted in Chapter 2, a primary challenge in formulating a public-
health strategy in response to indoor dampness is that there is no generally
accepted definition of dampness or what constitutes a "dampness problem"
and no generally-accepted metric for characterizing dampness. Studies of
specific populations conducted as part of research projects (summarized in
Table 2-1) show a wide range of estimates of the number of homes with
dampness problems or water damage. In recognition of that diversity, the
committee recommends that precise, agreed-on definitions of "dampness"
be developed to facilitate greater uniformity (and thus comparability) in the
data collected by researchers and the actions taken by those involved in
prevention and remediation. That will permit important information to be
gathered about mechanisms by which dampness and dampness-related ef-
fects and exposures affect occupant health.
Efforts to survey the prevalence of indoor allergens and other environ-
mental health risk factors comprehensively have also been carried out. The
National Survey of Lead and Allergens in Housing (NSLAH) was designed
to assess the potential exposure of children to a variety of agents, including
bacterial endotoxins and allergens of the fungus Alternaria alternata (Vojta
et al., 2002). A companion study--the First National Environmental Health
Survey of Child Care Centers--used methods similar to those of NSLAH to
evaluate exposures in licensed day-care centers (Viet et al., 2003). Both
efforts collected qualitative information on the presence of dampness and
mold. Publications describing the findings of those studies were in prepara-
tion or in press when the present report was completed.
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THE PUBLIC HEALTH RESPONSE 317
The committee did not identify any current surveillance of mold or
other dampness-related exposures in homes.3 A Connecticut law, however,
establishes requirements for assessment and monitoring efforts in the state's
public schools: Public Act 03-220, "An Act Concerning Indoor Air Quality
in Schools," requires boards of education to provide for a uniform program
of inspection and evaluation of indoor air quality in schools, citing the
Environmental Protection Agency (EPA) Indoor Air Quality Tools for
Schools Program (U.S. EPA, 2000) as an example. The program includes
review, inspection, or evaluation of the "potential for exposure to micro-
biological airborne particles, including, but not limited to, fungi, mold and
bacteria"; moisture incursion; and a number of other building and mainte-
nance factors related to indoor air quality. Boards of education are required
to perform an evaluation before January 1, 2008, and every 5 years there-
after of every school building that is or has been constructed, extended,
renovated, or replaced on or after January 1, 2003. No information on the
implementation of the law was available at the time the present report was
completed.
Despite its intuitive appeal, there is reason to have modest expectations
about the extent to which general surveillance for indoor microbial agents
would inform public-health decision-making at this point. As was men-
tioned in Chapter 3, no exposure standards have been established for molds
or other dampness-related agents, although some occupational-exposure
limitations were under discussion at the time this report was completed.
Among the factors hindering the development of standards are uncertain-
ties over which dampness-related exposures and at what exposure levels
may be harmful and limitations associated with all the established means of
exposure measurement. Qualitative indicators of the presence of mold also
have limitations. The presence of visible mold--even toxigenic genera--is
not an absolute indicator that health problems will result. The absence of
visible mold also is not an absolute indicator that a building is free of
infestation; there may be hidden sources.
The committee recommends (Chapter 2) that the determinants of damp-
ness problems in buildings be studied to ascertain where to focus interven-
tion efforts and health-effects research. The present state of the science,
however, is insufficient to support a general assessment and monitoring
effort for mold or other dampness-related agents for public-health policy
purposes.
3Periodic inspections of rental properties and public housing for mold were proposed
as part of the U.S. Toxic Mold Safety and Protection Act of 2003 (the Melina Bill); HR
1268, 108th Congress, 1st session. However, the version of this legislation introduced on
March 13, 2003, did not include provisions for compiling the information gathered in these
inspections.
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318 DAMP INDOOR SPACES AND HEALTH
Modification of Regulations, Building Codes, and
Building-Related Contracts
As detailed in Chapter 6, the use of suitable materials, appropriate design
and construction techniques, and common-sense maintenance practices can
be expected to prevent or dramatically reduce building dampness and prob-
lematic water accumulation. Existing local, state, and national codes and
methods of code enforcement may not, however, be sufficient to ensure that
good practices are implemented. Indeed, some existing codes may inadvert-
ently promote dampness. Chapter 2 notes, for example, that most codes
require passive or active ventilation of crawl spaces; the entry of warm,
humid outdoor air into ventilated crawl spaces, which are often cooler than
outdoors, is a moisture source for the crawl space.
Some official entities have introduced code provisions that specifically
address building dampness. In 2002, the California Occupational Safety
and Health Standards Board promulgated the following new section in its
"General Industry Safety Orders":
(g) When exterior water intrusion, leakage from interior water sources, or
other uncontrolled accumulation of water occurs, the intrusion, leakage
or accumulation shall be corrected because of the potential for these con-
ditions to cause the growth of mold. (Chapter 4, Subchapter 7, Article 9,
§3362)
Numerous codes address water and moisture control and ventilation
in general (Alliance for Healthy Homes, 2003). However, many of them
"are based primarily on practical experience within the building sector
or on non-health-related criteria such as perceived acceptability of air
(for example, immediate perception of odor or irritation)" (Mendell et al.,
2002). The effectiveness and cost effectiveness of codes with regard to
health-risk reduction have not been systematically studied. The commit-
tee thus recommends, on the basis of its review of the evidence presented
in Chapter 2, that current building codes be reviewed and modified as
necessary to reduce dampness problems. It cannot draw any informed
conclusions about code enforcement, but common sense suggests that
more-rigorous enforcement--especially in low-income housing--may yield
health benefits for residents.
Another strategy that might be considered is changes in contracts--
lease agreements, professional liability-insurance terms, contracts between
builders and owners, maintenance contracts, and the like--that would pro-
mote building design, construction, operation, and maintenance practices
that reduce the potential for dampness problems or that would clarify the
responsibilities of parties. Model contract language could be formulated by
consensus groups for possible use by individuals or in communities.
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THE PUBLIC HEALTH RESPONSE 319
Economic and Other Incentives
Action on the part of residents living in damp environments, builders,
building owners, and other stakeholders will be required to change the
present level of effort applied to preventing or reducing building damp-
ness. Economic incentives are one well-established means of achieving
such policy goals. Although specific examples of incentives for policy
change related to the prevention of damp environments could not be
located, there is precedent for using them in fire prevention and energy
efficiency. Mills (2003) cites several examples of premium reductions and
other incentives for actions and training that promote fuel conservation
and for safety measures that result in cost savings to the insured and
insurers. Such strategies depend on actuarially sound methods for quanti-
fying problems and assessing expected benefits--a feature that poses con-
siderable challenges when applied to the assessment of health effects of
damp buildings. However, estimates of the health and productivity gains
resulting from improvements in indoor environmental characteristics in
general have been generated, and these suggest that the benefits may be
considerable (Fisk, 2000).
Chapter 2 indicates that research is needed to determine the societal
cost of dampness problems and to quantify the economic effects of design,
construction, and maintenance practices that prevent or limit dampness
problems. Such data would facilitate more informed evaluation of the pri-
ority that should be assigned to dampness interventions in the wide spec-
trum of housing-related issues. Inasmuch as housing stock, climatic condi-
tions, and other factors vary across the country, this research may best be
conducted on a state level (via departments of health or departments of
social services) or a regional level, perhaps with a common protocol and
funding. Climate, geography, and building type all influence indoor mois-
ture levels and shape which problems are most likely to occur and which
interventions may be most effective.
Incentives that address dampness might take several forms. The com-
mittee did not address the topic in detail, but it offers the following as
examples of studies or experiments that might be undertaken to assess their
effectiveness in reducing dampness problems:
· Governments could provide tax incentives, low-interest loans,
streamlined application procedures, or other means to facilitate dampness-
remediation efforts. For example, a provision of Connecticut Public Act
03-220 allows the state commissioner of education to approve applications
for grants in excess of $100,000 for projects to remedy a "certified school
indoor air quality emergency" (as determined by the state Department of
Public Health) without seeking legislative approval.
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320 DAMP INDOOR SPACES AND HEALTH
· Health departments could be given permission to levy fines if water-
leak problems in rental properties are not corrected after a specified period.
· Those responsible for the maintenance of public housing, office
buildings, or schools could receive bonuses for meeting a defined set of
goals for the prevention or reduction of dampness-related conditions (such
as leaky roofs) or problems. Such programs could first be pilot-tested in
government-owned buildings.
Guidelines for the Prevention of Dampness-Related Problems
Chapter 6 discusses several sets of guidelines for the assessment and
management of mold-remediation activities that were developed by various
government agencies and professional organizations. However, there is a
lack of analogous guidance on preventing--or, more realistically, limiting
the opportunity for--the conditions that might precipitate the need for such
remediation. Guidelines are typically easier to develop than regulations or
other more formal instruments but can still have great effect if they earn
status as professional standards of care.
Prevention is a foundation principle in public health, and the commit-
tee believes that there is a need to develop and disseminate guidelines on
building design, construction, operation, and maintenance for prevention
of problematic damp indoor environments. Ideally, development should
take place at the national level to promote their widespread adoption and
help to avoid the proliferation of multiple and possibly conflicting sets of
advice. Stakeholder groups should play an active role in providing input for
the guidelines, but they should not be the organizing or sanctioning body
for the effort in order to promote its credibility and general acceptance. The
committee suggests that any effort to develop guidelines for prevention of
problematic damp indoor environments take the following considerations
into account:
· The guidelines should be formulated with multidisciplinary input
and with input from a wide array of stakeholders.4
· The costs of implementing actions should be evaluated and their
expected benefits identified.
· The guidelines should account for how differences in climate, geog-
raphy, building type, and building age influence vulnerabilities to dampness
and the best approaches to prevention.
4In 1995, participants in a workshop on indoor air convened by the American Thoracic
Society decried the lack of venues where professionals working in the field could interact.
They recommended that the Society and the American Lung Association "take the lead in
conducting regular interdisciplinary workshops that promote in-depth discussion of key and
timely issues" (ATS, 1997).
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THE PUBLIC HEALTH RESPONSE 321
· To be effective, the guidelines should go beyond simple prescriptive
application of available science and technology; professional judgment
should be allowed.
· Draft guidelines should be subject to external review.
Because the prevention of problematic dampness is just one of a set of
interrelated factors that can affect the indoor environment and the health of
its occupants, consideration should also be given to developing the guide-
lines in the context of a wider set of principles that guide the creation and
maintenance of healthy buildings.
Public-Health-Oriented Research and Demonstration
Prevention and control of building dampness are hampered by the lack
of evidence regarding the effectiveness of various interventions. Clearing
the Air (IOM, 2000), for example, acknowledged the logic of reducing
dampness as a method for reducing asthma symptoms related to indoor
dampness but noted that "no intervention studies clearly document that
any form of dampness control works effectively to reduce symptoms or to
reduce chances of asthma development." Additional support for that obser-
vation is provided in Chapters 2 and 6 of the present report.
Although there are references in the public-health literature to house-
hold-level housing interventions to improve health status, randomized
controlled trials are comparatively rare. A review of studies of the rela-
tionship between housing interventions and improvements in health iden-
tified only 18 (11 prospective and seven retrospective) that evaluated
effects on health, illness, and a variety of social measures (Thomson et al.,
2001). Only six of the prospective studies and three of the retrospective
studies included a control group. The researchers found that many stud-
ies showed improvements in self-reported health or reductions in symp-
toms after the intervention, but "small study populations and the lack of
controlling for confounders limit the generalisability of these findings"
(Thomson et al., 2001).
A later review by Saegert et al. (2003) examined a wider array of
intervention studies but restricted the analysis to investigations conducted
in the United States in 19902001. They found 72 studies; 21 (29%) ad-
dressed asthma triggers or air-quality hazards (including moisture or mold).
Among the characteristics noted was that 85% of the interventions were
one-time efforts--a single training program, cleaning or remediation. The
type of intervention performed was almost evenly split among environ-
mental improvements (31%), participant education (32%), or both (35%).
Although 81% of the studies reported the interventions to be successful,
only 51% indicated that the measured improvement was sustained. The
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322 DAMP INDOOR SPACES AND HEALTH
authors observed that some common factors were associated with success
in intervention studies:
· "Technological interventions appear most successful when the tech-
nology is effective, cheap, and durable and requires little effort to maintain
or use. Such interventions are especially effective if accompanied by behav-
ioral or knowledge training, and if hazard amelioration can be successfully
accomplished through individual-level efforts alone."
· "Involving people more deeply in the solution of health problems,
especially by home visits, appears to be especially effective and can improve
multiple health outcomes."
The Seattle-King County Healthy Homes Project (Krieger et al., 2000,
2002, 2003) is among recent demonstration and research efforts that in-
cluded a moisture or mold component. The project targeted 274 low-
income households in the Seattle area that included a child with diagnosed
asthma. Participants were randomly assigned to a "high-intensity" group
(n = 138), which received comprehensive intervention services, or a "low-
intensity" group (n = 136), which received a single home visit and limited
services. (The low-intensity group received additional services at the comple-
tion of the 1-year study period.) For the high-intensity group, community
health workers provided home assessments of several potential allergens
associated with asthma and other risk factors (including dust, house dust
mites, cockroaches, environmental tobacco smoke, rodents, and pesticides),
followup education on how to prevent their occurrence or limit their ef-
fects, and in some circumstances active interventions to change the indoor
environment. The mold and moisture portion of the assessment found that
77% of participant homes had "moisture problems" and over 20% had
signs of water intrusion (Krieger et al., 2002). Several possible interventions
were identified, including education on moisture sources and barriers, pro-
vision of cleaning materials, replacement of moldy shower curtains, instal-
lation or inspection and cleaning of ventilation fans, plugging of holes
leading to the interior, and installation of vapor barriers. However, the
authors noted that implementation of some of the more rigorous building
interventions was beyond the resources of the study and that participants
did not have the means to perform them independently. At the end of the
study period, children in the high-intensity group experienced a greater
decrease in asthma-symptom days (4.7; 95% CI, 3.65.9; vs 3.9; 2.65.2)
and a statistically significant decrease in urgent health-services use (15%;
6.323.6%; vs 3.8%; 13.15.4%) compared with the low-intensity chil-
dren (Krieger et al., 2003). That translated to an estimated $6,3018,854
savings in urgent-care costs over a 2-month period relative to the low-
intensity group. "Excessive moisture" in the home was reported to have
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THE PUBLIC HEALTH RESPONSE 323
decreased significantly in the high-intensity group,5 whereas no significant
changes occurred in the low-intensity group; no changes in the presence of
mold were observed in either group. The degree to which the improvements
were a consequence of the dampness-related portion of the intervention
program is not known.
The Seattle effort and similar ones conducted as part of the National
Cooperative Inner-City Asthma Study (Crain et al., 2002; Sullivan et al.,
2002) and in Detroit (Parker et al., 2003) show that interventions at both
the household and community levels can be mounted and targeted at a
specific disease for susceptible people. Local health jurisdictions--such as
Boston, Cleveland, and New York City--have developed comparable com-
munity wide "Healthy Homes" initiatives related to asthma and chemical
hazards (Krieger and Higgins, 2002).
The Department of Housing and Urban Development (HUD) has pro-
vided grants to the Cuyahoga County (Ohio) Department of Development
and the Illinois Department of Health to fund targeted mold and moisture
interventions under its Healthy Homes Initiative (HUD, 2003a). The pro-
grams include education; environmental, biologic, and medical monitor-
ing; and in some cases remediation. The projects are going on now, and no
results had been published as of late 2003.
Virtually no data are available to compare effects of different interven-
tions and intervention strategies. There is thus insufficient information to
draw conclusions on the benefits of specific public-health-oriented housing
interventions specifically related to moisture or mold. Existing research on
exposure to indoor environmental agents in general suggests that targeted,
intensive interventions may yield health benefits. And, as documented in
Chapter 6, there is universal agreement that prompt remediation of water
intrusion, leaks, spills, and standing water substantially reduces the poten-
tial for growth of dampness-related microbial agents and dampness-related
degradation of building materials and furnishings.
The committee recommends that carefully designed and controlled lon-
gitudinal research be undertaken to assess the effects of population-based
housing interventions on dampness and to identify effective and efficient
strategies. As part of such studies, attention should be paid to definitions of
dampness and to measures of effect; and the extent to which interventions
are associated with decreased occurrence of specific negative health condi-
tions should be assessed when possible.
5Floor dust loading, roach activity, and a composite measure of exposure to asthma trig-
gers also decreased significantly in the high intensity group. It must be remembered that all of
these environmental factors are thought to affect asthma outcomes and that the high interven-
tion group also changed several behaviors thought to influence asthma exacerbation. The
authors did not attribute the improvement in health outcomes to any one factor.
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324 DAMP INDOOR SPACES AND HEALTH
Education and Training
If prevention of potentially problematic damp indoor environments is
to be achieved, public education and training of professionals will be inte-
gral parts of the solution.
Education and outreach to citizens--especially those in vulnerable com-
munities--could have a large role in preventing or limiting the future effects
of damp indoor environments. The research and demonstration projects
referred to above that included education and training components are
examples of how this might be accomplished in targeted, intensive interven-
tions. Most efforts undertaken to date, however, have been simply the
provision of information. Several federal agencies--including EPA (EPA,
2002), the Federal Emergency Management Agency (FEMA, 2003), and
HUD and the U.S. Department of Agriculture (Healthy Homes Partnership,
2003)--have, for example, published guidance on identifying and reme-
diating problematic dampness and mold in the home. Some states, includ-
ing Minnesota (MDH, 2003), and such cities as New York (NYCDOH,
2002) also provide dampness-remediation information on their health-
department Web sites. However, the committee did not identify any assess-
ments of public awareness of such information, its distribution outside
households with Internet access, or its diffusion to individuals concerned
with dampness or mold problems.
Chapter 2 notes that although technical information on controlling
moisture in residences and larger buildings has been developed and pub-
lished (Lstiburek, 2001, 2002; Lstiburek and Carmody, 1996; Rose, 1997),
anecdotal experience suggests that architects, engineers, facility managers,
and contractors in the building trades often do not apply it when designing,
constructing, or maintaining buildings. The chapter recommends that these
building professionals receive better training on how and why dampness
problems occur and on their prevention. The committee specifically rec-
ommends that a curriculum be developed for the training of building in-
spectors so that they can identify and require correction of common con-
struction errors that lead to dampness problems; the curriculum should be
disseminated broadly.
At the time this report was completed (late 2003), the mold assessment
and remediation industry in the United States was largely nonregulated;
laws regarding specific standards for education and training of practitio-
ners were just coming into effect in Louisiana (Act 880; effective August 15,
2003) and Texas (HB 329; effective September 1, 2003). In the absence of
government standards, a number of groups have created "certifications"
with widely varied requirements for instruction, testing, and continuing
education. The committee did not undertake to evaluate them.
Many allergy and pulmonary-medicine specialists (especially those prac-
ticing in areas with large agricultural populations) have experience in deal-
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THE PUBLIC HEALTH RESPONSE 325
ing with patients who have experienced adverse health effects due to expo-
sure to mold, endotoxin, or organic dust. In general, however, physicians
and other health-care providers are not well educated in the diagnosis and
treatment of environmental health-related problems (IOM, 1995). Recog-
nizing that, the IOM Committee on Curriculum Development in Environ-
mental Medicine (IOM, 1995) identified five competence objectives related
to the clinical management of patients, stating that graduating medical stu-
dents should
· Understand the influence of the environment and environmental
agents on human health based on knowledge of relevant epidemiologic,
toxicologic, and exposure factors.
· Be able to recognize the signs, symptoms, diseases, and sources of
exposure relating to common environmental agents and conditions.
· Be able to elicit an appropriately detailed environmental exposure
history, including a work history, from all patients.
· Be able to identify and access the informational, clinical, and other
resources available to help address patient and community environmental
health problems and concerns.
· Be able to discuss environmental risks with their patients and pro-
vide understandable information about risk-reduction strategies in ways
that exhibit sensitivity to patients' health beliefs and concerns.
Such proficiency clearly would be of benefit in addressing health issues that
might be related to indoor dampness. The committee is aware that guidance
to physicians on the recognition and management of health effects related
to indoor mold exposure was being developed when this report was com-
pleted, but there were no publicly available documents for its review.
Public health professionals, particularly those who work in environ-
mental health, will increasingly be required to assist in drafting recommen-
dations for the prevention of excessive building dampness and the imple-
mentation of interventions to eliminate microbial contamination in affected
buildings. It follows that their training should develop competence in the
recognition of and appropriate response to problematic indoor dampness in
workplace settings and in housing. Public health departments should assist
in the development of educational campaigns to alert members of the gen-
eral public to the risks associated with indoor dampness.
Environmental health is identified as a core component of public health
education (IOM, 2003), and some courses related to indoor dampness and
mold have been accredited for continuing education for public-health and
industrial-hygiene professionals. Awareness of the possible health implica-
tions of damp indoor spaces in the public-health community has not, how-
ever, been examined.
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326 DAMP INDOOR SPACES AND HEALTH
Education is a common component of public-health interventions be-
cause it is relatively inexpensive and, at least in some circumstances, has
been shown to be effective. A great deal of information is at least poten-
tially available to citizens and to the various health and building profession-
als whose work is related to indoor environments, but little research has
been conducted to evaluate whether it is reaching the right people or affect-
ing their responses to possibly problematic dampness in buildings. The
committee recommends that such research be conducted. Those formulat-
ing public-health interventions should examine asthma-education efforts,
which may yield clues to effective strategies for communicating information
on environmental health risks and effecting favorable changes in subjects'
behavior. Any efforts undertaken need to include rigorous assessments of
their short-term and long-term impacts. Six aspects of such education ef-
forts merit attention:
· Do they raise awareness of potentially problematic conditions and
exposures?
· Are they culturally and linguistically appropriate?
· Are they reaching vulnerable populations--those that are at high
risk for dampness problems or adverse health outcomes?
· Do they effect changes in behavior that result in decreases in expo-
sure or risk?
· Are changes sustained?
· Do the efforts address the possible role of the media and local and
community-based organizations or institutions (such as schools and
churches) in raising public awareness?
Collaboration
Implementation of the recommendations in this report will require
collaboration with and among stakeholders in public health. Health depart-
ments, housing authorities, policy-makers, insurers, community-based or-
ganizations, and voluntary agencies will need to coordinate efforts to advo-
cate for and effect the research efforts and changes in policy proposed here.
At least two collaborative approaches seem reasonable for introducing
or furthering the prevention and control of damp indoor environments. The
first is to integrate, or better integrate, dampness considerations into cur-
rent efforts. HUD's Healthy Homes Initiative--which focuses on "research-
ing and demonstrating low-cost, effective home hazard assessment and
intervention methods, as well as on public education that stresses ways in
which communities can mitigate housing-related hazards" (HUD, 2003b)--
is one vehicle for promoting strategies that emphasize prevention of damp-
ness. Another is the many respiratory-health-related, communitywide coali-
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THE PUBLIC HEALTH RESPONSE 327
tions in the United States. A 2000 survey identified 63 asthma coalitions of
varied size and resources (ACCP, 2000), and there were about 150 such
organizations across the United States at the end of 2003 (Allies Against
Asthma, 2003). Chapter 5 notes that the scientific literature supports an
association between dampness and asthma exacerbation; it is appropriate
to integrate dampness initiatives into coalition-led programs that do not
have them.
A second approach is to develop new communitywide partnerships
to address the specific prevention of potentially problematic damp indoor
environments. Some aspects of dampness and the exposures that it pro-
motes are unrelated to asthma or respiratory disease. It is possible and
perhaps desirable to form collaborations that bring the stakeholders (in-
cluding occupants and tenant organizations) together and focus them on
effective actions in their mutual interest. Mobilization of stakeholders and
communitywide approaches may be particularly important in low-income
areas, where resources are scarce. The new partnerships may attract stake-
holders not usually evident in community health-related endeavors--for
example, building professionals--who can lend new perspectives to efforts
to affect change.
FINDINGS, RECOMMENDATIONS, AND RESEARCH NEEDS
On the basis of the review of the papers, reports, and other information
presented in this chapter, the committee has reached the following findings
and recommendations and has identified the following research needs
regarding the public-health dimension of damp indoor environments. Pre-
ceding chapters of this report provide the foundation for some the recom-
mendations and offer additional observations on health, building, and
prevention and remediation issues.
Findings
· Excessive indoor dampness is a public-health problem: dampness is
prevalent in residential housing in a wide array of climates; sufficient evi-
dence of an association exists between signs of dampness and upper respira-
tory tract symptoms, cough, wheeze, and asthma symptoms in sensitized
persons; and sufficient evidence of an association exists between signs of
mold and upper respiratory tract symptoms, cough, wheeze, asthma symp-
toms in sensitized persons and hypersensitivity pneumonitis in susceptible
persons.
· In the absence of a generally accepted definition of dampness or
what constitutes a "dampness problem," the advice offered in remediation
guidelines developed by government and well-established professional asso-
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328 DAMP INDOOR SPACES AND HEALTH
ciations can serve as references for when and what level of response is
appropriate.
· Indoor dampness has an economic dimension. Economic factors may
encourage poor building design and construction practices; they may also
create incentives to forgo or limit investment in maintenance and other
measures that might help to prevent or reduce moisture problems. Cost-
effectiveness studies are needed to assess the savings that damp-building
prevention or remediation might generate.
· An appropriate public health goal should be to prevent or reduce the
incidence of potentially problematic damp indoor environments, that is,
environments that may be associated with undesirable health effects, par-
ticularly in vulnerable populations. However, there are serious challenges
associated with achieving that goal, given the lack of information on key
scientific questions regarding the health effects of dampness-related agents,
and questions of exposure and dose.
Recommendations and Research Needs
· CDC, other public-health-related, and building-management-related
funders should provide new or continuing support for research and dem-
onstration projects that address the potential and relative benefit of various
strategies for the prevention or reduction of damp indoor environments,
including data acquisition through assessment and monitoring, building
code modification or enhanced enforcement, contract language changes,
economic and other incentives, and education and training. These projects
should include assessments of the economic effects of preventing building
dampness and repairing damp buildings and should evaluate the savings
generated from reductions in morbidity and gains in the useful life of struc-
tures and their components associated with such interventions.
· Carefully designed and controlled longitudinal research should be
undertaken to assess the effects of population-based housing interventions
on dampness and to identify effective and efficient strategies. As part of
such studies, attention should be paid to definitions of dampness and to
measures of effect; and the extent to which interventions are associated
with decreased occurrence of specific negative health conditions should be
assessed when possible.
· Government agencies with housing-management responsibility should
evaluate the benefit of adopting economic-incentive programs designed to
reward actions that prevent or reduce building dampness. Ideally, these
should be coupled with independent assessments of effectiveness.
· HUD or another appropriate government agency with responsibility
for building issues should provide support for the development and dis-
semination of consensus guidelines on building design, construction, opera-
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THE PUBLIC HEALTH RESPONSE 329
tion, and maintenance for prevention of dampness problems. Development
of the guidelines should take place at the national level and should be under
the aegis of either a government body or an independent nongovernment
organization that is not affiliated with the stakeholders on the issue.
· CDC and other public-health-related funders should provide new or
continuing support for research and demonstration projects that:
-- Develop communication instruments to disseminate information
derived from the scientific evidence base regarding indoor dampness, mold
and other dampness-related exposures, and health outcomes to address
public concerns about the risk from dampness-related exposures, indoor
conditions, and causes of ill health.
-- Foster education and training for clinicians and public-health pro-
fessionals on the potential health implications of damp indoor environments.
· Government and private entities with building design, construction,
and management interests should provide new or continuing support for
research and demonstration projects that develop education and training
for building professionals (architects, home builders, facility managers and
maintenance staff, code officials, and insurers) on how and why dampness
problems occur and how to prevent them.
· Those formulating the education and training programs discussed
above should include means of evaluating whether their programs are reach-
ing relevant persons and, ideally, whether they materially affect the oc-
currence of moisture or microbial contamination in buildings or occupant
health.
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