p. 1 

Research I 

Fungal Levels in the Home and Allergic Rhinitis by 5 Years of Age 

Paul C. Stark, t Juan C. Celeddn,2 Ginger L. Chew,' Louise M. Ryan,4 Harriet A. Burge,5 Michael L. Muilenberg,5 

and Diane R. Gold 2 

'Biostatistics Research Center, Institute for Clinical Research and Health Policy Studies, Department of Medicine, Tufts-New England 

Medical Center, Boston, Massachusetts, USA; ZChanning Laboratory, Department of Medicine, Brigham and Women's Hospital and the 

Harvard Medical School, Boston, Massachusetts, USA; 3Department of Environmental Health Sciences, Mailman School of Public Health, 

Columbia University, New York, New York, USA; 4Department of Biostatistics, and 5Department of Environmental Health, Harvard 

University School of Public Health, Boston, Massachusetts, USA 

Studies have repeatedly demonstrated that sensitization to fungi, such as Alternaria, is strongly 

associated with allergic rhinitis and asthma in children. However, the role of exposure to fungi in 

the development of childhood allergic rhinitis is poorly understood. In a prospective birth cohort of 

405 children of asthmatic/allergic parents from metropolitan Boston, Massachusetts, we examined 

in-home high fungal concentrations (> 90th percentile) measured once within the first 3 months of 

life as predictors of doctor-diagnosed allergic rhinitis in the first 5 years of life. In multivariate Cox 

regression analyses, predictors of allergic rhinitis included high levels of dust-borne Aspergillus 

[hazard ratio (HR) = 3.27; 95% confidence interval (CI), 1 .50-7.141, Aureobasidium (HR = 3.04; 

95% CI, 1.33-6.93), and yeasts (HR = 2.67; 95% CI, 1 .2Cr5.66) . The factors controlled for in 

these analyses included water damage or mild or mildew in the building during the first year of the 

child's life, any lower respiratory tract infection in the first year, male sex, African-American race, 

fall date of birth, and maternal IgE to Alternaria > 0.35 U/mL. Dust-borne Alternaria and nonsporulating and total fungi were also predictors of allergic rhinitis in models excluding other fungi 

but adjusting for all of the potential confounders listed above. High measured fungal concentrations and reports of water damage, mold, or mildew in homes may predispose children with a family history of asthma or allergy to the development of allergic rhinitis . Key words: allergic rhinitis, 

fungi, mold, respiratory health effects, water damage. Environ Healtb Perspect 113:1405-1409 

(2005) . doi:10.1289/ehp.7844 available via bttp://dr.doi.org/[Online 20 May 20051 

Studies have repeatedly demonstrated that 

sensitization to fungi, such as Alternaria, is 

strongly associated with allergic rhinitis and 

asthma in children (Arshad et al . 2001 ; Downs 

et al . 2001; Halonen et al . 1997; Nolles et al. 

2001) . However, the role of exposure to fungi, 

measured in environmental samples, in the 

development of childhood allergic rhinitis is 

poorly understood . Allergic rhinitis affects an 

estimated 20--40 million people in the United 

States alone, and the incidence is increasing. 

Allergic rhinitis has been associated with snoring, sleep apnea, and sleep disturbances in children (Camhi et al . 2000; Corbo et al . 2001; 

Scharf and Cohen 1998). The prevalence of 

symptoms of allergic rhinoconjunctivitis 

ranged between 15 and 25% among children 

13-14 years of age who lived in the United 

States or the United Kingdom (International 

Study of Asthma and Allergies in Childhood 

1998) . A recent study documented that 93% 

of adolescents with allergic asthma also have 

allergic rhinitis . The diagnosis of allergic rhinitis preceded asthma in up to 64% of patients 

with both diseases (Kapsali et al . 1997). 

Because allergic rhinitis is a common disease 

that lessens quality of life and is associated with 

significant morbidity, determining environmental exposures associated with the development of allergic rhinitis is of great public 

health importance . 

In a prospective birth-cohort study of 

children with parental history of asthma or 

allergies, we assessed environmental fungal 

exposure (culturable fungi in house air and 

dust samples) and evaluated whether high 

fungal levels were independently associated 

with doctor-diagnosed allergic rhinitis in the 

first 5 years of life . 

Materials and Methods 

Study protocol. Participants were part of a 

metropolitan Boston, Massachusetts, prospective birth-cohort study designed to examine 

relationships between amounts of indoor allergens, including fungi, and the development of 

allergy and asthma. The study was approved 

by the institutional review board of Brigham 

and Women's Hospital . With the consent of 

the primary caregiver, screening and recruitment of the families, which we have previously described (Gold et al . 1999), was 

conducted between September 1994 and June 

1996. Monday through Friday, all mothers 

who delivered at Brigham and Women's 

Hospital, a large Boston hospital, were 

approached for screening within 24-48 hr 

after delivery. Eligibility criteria included residence inside route 128 (a highway encircling 

the Boston metropolitan area) ; maternal age 

>_ 18 years ; history of hay fever, asthma, or 

allergies in either parent; and maternal ability 

to speak English or Spanish. Families were 

not screened if the newborn was hospitalized 

in the intensive care unit, was of gestational 

age < 36 weeks, or had a congenital anomaly. 

One month after birth, a questionnaire 

regarding the child's health was administered 

by telephone to families who had initially 

expressed interest in participating in the study 

and who fit the inclusion criteria . At 1 month, 

parents who expressed plans to move or lack 

of interest in the study were also excluded. 

Of the 1,405 families screened, 906 were 

excluded from the study before the initial 

home visit . Reasons for exclusion were reluctance to participate in a longitudinal study 

(51%), plans to move within 1 year (39%), 

early loss to follow-up (9%), and other (1%). 

After written informed consent was obtained, 

a home visit was made when the child was 

2-3 months of age, and a questionnaire 

regarding health outcomes, home characteristics, environmental exposures, smoking, and 

demographics was administered by trained 

research assistants . Every- 2 months, beginning 

when the child was 2 months old and continuing until the second birthday, a telephone 

questionnaire was administered to the child's 

primary caretaker . After that, health outcomes 

were ascertained semiannually. 

At the initial home visit, indoor air samples were collected from each home using a 

Burkard culture plate sampler (Burkard 

Manufacturing Co. Ltd., Hertfordshire, UK) 

operated at 45 L/min [calculated cut point, 

diameter allowing 50% (Dgo) = 2 pm] that 

collected particles onto DG 18 agar (a glucose 

medium containing dichloran and 18% glycerol) in 90-mm Petri dishes . Sequential duplicate 1-min air samples were collected in the 

bedroom 1-1 .5 m above the area of the floor 

demarcated for dust collection . After sampling, the Petri plates were returned to the 

laboratory on the same day for incubation . 

Address correspondence to P.C. Stark, Biostatistics 

Research Center, Institute for Clinical Research and 

Health Policy Studies, Tufts-New England Medical 

Center, 750 Washington St ., Tufts-NEMC #63, 

Boston, MA 02111 USA. Telephone: (617) 636-5457 . 

Fax: (617) 636-5560 . E-mail : pstark@mfts-nemc .org 

We thank the participating families for their 

enthusiastic participation . We also thank C. Rogers 

and D. Sredl for their efforts . 

This study was supported by National Institutes of 

Health grant AI/EHS35786 . P .C .S . was supported 

by the Yamaguchi Endowment. 

The authors declare they have no competing 

financial interests . 

Received 10 December 2004 ; accepted 19 May 

2005 . 

Environmental Health Perspectives " VOLUME 113 1 NUMBER 10 1 October 2005 1405 
Stark et al . 

The sampler sieve plate was cleaned with an 

isopropanol swab after each home visit . 

After air samples were collected, 2 m2 of 

the floor surrounding the newborn's bed was 

vacuumed for 5 min, using a Eureka MightyMite canister vacuum cleaner (Eureka Co ., 

Bloomington, IN) modified to collect dust in 

a 19- x 90-mm cellulose extraction thimble 

(Whatman International Ltd., Herefordshire, 

UK) . In cases where both a smooth floor and 

a rug were present, 2.5 min was devoted to 

sampling the rug and 2.5 min was spent vacuuming the smooth floor surface . After sampling, the thimble was sealed in a plastic bag 

and returned to the laboratory for sifting 

(425-1tm mesh sieve) and weighing. 

A weighed aliquot of fine dust from the 

dust sampling was suspended (- 25 mg/mL) 

and serially diluted (e .g ., full strength, 

1 :10, and 1 :100) in an aqueous solution of 

0.02% Tween. Duplicates of each dilution 

were spread-plated on DG18 culture media 

(Verhoeff et al . 1994). After a mean t SD 

incubation period of 27 .9 f 14.5 days, we 

identified fungal colonies on both air- and 

dust-sample plates to genus (subgenus in the 

case of Aspergillus isolates) using standard 

mycologic criteria (Ellis 1971 ; von Arx 1970) . 

We adjusted the number of colonies recovered on the air sample plates for possible 

multiple impactions using the positive-hole 

correction equation (Andersen 1958) . The 

calculated concentrations of dust-borne fungi 

were the number of colony-forming units 

(chi) per gram of dust, and those of airborne 

fungi were cfu per cubic meter of air . We prioritized the use of limited amounts of dust 

collected from a home so that measurement 

of allergens for cockroach, cat, and dust mites 

could be performed first (Chew et al . 1998), 

followed by analyses of fungi and endotoxin, 

respectively . If there was not enough dust for 

allergen analyses, then the fungal analyses 

were performed first . Thus, when there was 

> 200 mg or < 25 mg dust collected, fungal 

concentrations were determined. There were 

84 children eliminated because the amount of 

dust collected was between 25 and 200 mg. 

Fungal data. In previous analyses of these 

data (Stark et al . 2003), we found that it was 

useful to create indices indicating high levels of 

fungi in the home. The variable was coded 1 if 

that home produced "high" levels of that fungus, and 0 otherwise . We define "high" as 

greater than the 90th percentile for each taxon . 

Based on Akaike's Information Criterion 

(Hastie and Tibshirani 1990) and -2 log likelihood, models with indices for high fungal 

levels fit the data better than do models treating the fungal concentrations as continuous or 

natural logarithm-transformed data . 

Definition ofallergic rhinitis and predictor 

variables. We assessed allergic rhinitis from 12 

to 60 months of age by asking "Has your child 

had allergic rhinitis or hay fever diagnosed by a 

doctor?" Children without 12-month followup (n = 10) were excluded, leaving 405 children with > 12 months of health outcome 

data, as well as fungal data. 

Definitions of other predictor variables. 

Sociodemographic, familial, and perinatal variables considered for inclusion in the multivariate analysis of the relation between indoor 

fungal exposure and allergic rhinitis included 

sex, season of birth [defined as winter 

(December-February), spring (March-May), 

summer (June-August), or fall (SeptemberNovember)], race/ethnicity of the child according to parental reporting (Litonjua et al. 1998), 

total annual family income (< $30,000, 

$30,000-50,000, and > $50,000), active 

maternal history of asthma (physician-diagnosed asthma and wheeze in the past year), 

maternal sensitization to Alternaria [specific 

immunoglobulin E (IgE) > 0 .35 U/mL], 

maternal smoking during pregnancy, and presence of older siblings in the household . 

Additional variables considered for inclusion in the multivariate analysis included 

report of any of the following in the child's 

first year of life : any physician-diagnosed lower 

respiratory tract infections (pneumonia, croup, 

bronchitis, or bronchiolitis), as determined by 

bimonthly questions to the child's primary 

caregiver (Celedon et al . 1999) ; visible water 

damage; mold or mildew inside the home; and 

report of water damage in the basement, presence of concrete floors in the baby's room, use 

of a dehumidifier, and use of an air conditioner . A composite variable representing the 

presence of either water damage or visible mold 

or mildew in the home in the child's first year 

of life was also examined. 

Statistical methods . All final models 

reported used survival analysis (Cox proportional hazards regression) to explore time to 

first report of doctor-diagnosed allergic rhinitis 

or hay fever. We performed initial exploratory 

analyses of univariate associations between 

allergic rhinitis and potential predictor variables using logistic regression, chi-square 

analyses, and Cox regression . We performed 

all statistical analyses using SAS statistical 

software (version 8 .2, SAS Institute Inc., Cary, 

NC) and S-Plus (version 6.1, Insightful 

Corporation, Seattle, WA). Multivariate models were constructed that included significant 

(P<- 0 .05) fungal taxa, significant independent 

predictors of allergic rhinitis, and variables 

that may confound the relationship between 

the fungal levels and allergic rhinitis . The proportional hazards assumption was validated in 

final models. 

Lasso approach. Multivariate models were 

independently validated using the lasso 

approach for model shrinkage described by 

Tibshirani (1997) . This technique prevents the 

tendency to overfit a model by constraining the 

effect that the variables will have in the model. 

This is one approach used to combat the 

multiple-comparison hazards that arise when 

so many different taxa of fungi need to be 

considered. 

Results 

Of the 405 children included in this analysis, 

52 (12 .8%) were diagnosed with allergic 

rhinitis or hay fever by a doctor before or at 

5 years of age . 

Relationship between cohort characteristics 

and allergic rhinitis . Table I shows the relationship between cohort characteristics and 

doctor-diagnosed allergic rhinitis by 5 years of 

age . Factors associated with an increased risk of 

allergic rhinitis included African-American ethnicity, being born between September and 

November, maternal sensitization to Alternaria 

(IgE to Alternaria > 0.35 U/mL), and having at 

least one lower respiratory tract illness in the 

first year of life. Male sex and water damage or 

mold or mildew in the building of residence 

within the first year of life were marginally 

associated with doctor-diagnosed allergic rhinitis by 5 years of age . 

In Table 2, we report the number of 

houses from which each taxon was cultured, 

and the value corresponding to the 90th percentile . Penicillium was the most common 

taxon sampled from the air, but Cladosporium, 

Penicillium, and nonsporulating fungi had the 

highest levels recovered from the air. From the 

dust samples, Aspergillus was most commonly 

recovered sporulating taxon, followed by 

Cladosporium. 

High levels of dust-borne Aureobasidium, 

Aspergillus, Alternaria, yeasts, and nonsporulating fungi as well as high levels of total fungi 

were independently associated with the development of doctor-diagnosed allergic rhinitis by 

5 years of age in analyses controlling for factors 

significantly associated with allergic rhinitis 

(Table 3) . These factors included water damage or mold or mildew in the building during 

the first year of the child's life, any lower respiratory tract illness in the first year, male sex, 

African-American race, birth date between 

September and November, and maternal IgE 

to Alternaria > 0.35 U/mL. 

In a multivariate adjusted proportional 

hazards regression analysis looking simultaneously at the effects of high fungal levels 

and significant independent predictors 

(Table 4), dust-borne Aspergillus [hazard ratio 

(HR) = 3 .27 ; 95% confidence interval (CI), 

1 .50-7 .14], Aureobasidium (HR = 3.04 ; 95% 

CI, 1 .33-6 .93), and yeasts (HR = 2.67 ; 95% 

Cl, 1 .26-5 .66) remained significantly associated with allergic rhinitis . Alternaria and 

Cladosporium were not significant in the multivariate model, because they are highly correlated with other fungi that were significant . 

Alternaria was significantly correlated with 

1406 VOLUME 113 1 NUMBER 10 1 October 2005 " Environmental Health Perspectives 
Fungal levels and allergic rhinitis 

Aureobasidium (R= 0.33, p < 0.0001) to the 

point where its contribution to the model is 

not statistically significant after considering the 

effect of Aureobasidium. When Aureobasidium 

is omitted from the model (Table 4, model 3), 

Alternaria is borderline significant (HR = 2.07 ; 

95% CI, 0.98-4.37) . Alternaria and Cladosporium were highly correlated as well (R = 

0.30, p < 0.0001) . Having high levels of total 

dust-borne fungi was not significant in multivariate models that had the specific taxa listed 

above (p = 0.44) . The magnitude and strength 

of these associations remained essentially 

unchanged when controlling for the presence 

of dust mite, cockroach, and cat allergens and 

endotoxin in the home, none of which had significant independent associations with allergic 

rhinitis by age 5 in multivariate models (data 

not shown) . 

Discussion 

High dust-borne fungal levels of Alternaria, 

Aspergillus, Aureobasidium, and yeasts measured 

in the home in the first 3 months of life were 

associated with the subsequent development of 

doctor-diagnosed allergic rhinitis within the 

first 5 years of life, independent of water damage or mold or mildew in the home, race, sex, 

season of birth, lower respiratory tract infection 

in the first year of life, and maternal IgE to 

Alternarla > 0.35 U/mL. Home dampness has 

been shown to be related to allergic rhinitis 

exacerbations (Kilpelainen et al. 2001), but to 

our knowledge, the relation of either water 

damage or mold/mildew or high levels of specific fungal taxa to the development of allergic 

rhinitis in childhood has not previously been 

reported . 

Although other studies have found associations between measures of total fungi and 

health outcomes (Gent et al. 2002), it is likely 

that, in our study, "total fungi" is a noisier 

estimate of relevant fungal exposures than are 

our other metrics of fungi . The measure of 

"total fungi" would combine fungi not likely 

to be related to rhinitis along with fungi that 

have been identified as being related to allergic sensitization . This could lead to less precise estimates of fungal heath effects and an 

attenuation of the relationship between fungi 

and allergic rhinitis . 

Fungal exposure is complex. Fungi can contain allergens, irritants, toxins, and sometimes 

even potentially infectious units (Johnston 

2000) . (1->3)-(3-D-Glucans-glucose polymers that are structural components of most 

fungal cell walls-are known to stimulate 

macrophages and neutrophils and have been 

shown to be good markers for the overall 

levels of fungal concentrations in floor dust 

(Chew et al . 2001) . Beijer et al . (2002) found 

that an inhalation challenge to (1---)3)-(3-Dglucans has an effect on the inflammatory cells, 

which may be related to chronic exposure to 

household molds. Fungi are ubiquitous, and 

exposure is impossible to completely avoid . 

Often, there are no adverse effects from these 

exposures (Macher 2000), but at times exposure to fungi can directly and indirectly influence an individual's health . Fungal exposure 

in sensitized individuals may result in histamine and IgE-mediated nasal inflammation 

(Skoner 2001) . Chronic exposure to fungi 

may also cause chronic nasal symptoms that 

are not allergic in nature, but rather caused 

by irritants (Daisey et al. 2003; Dotterud et al . 

1996) . Symptoms of allergic rhinitis are similar to the chronic nasal symptoms often found 

with sick building syndrome. Given that fungi 

may play a role in sick building syndrome as 

well (Scheel et al . 2001), differentiation may 

be difficult . 

In previous articles we have reported that 

endotoxin was a risk factor for wheeze (Park 

et al . 2001) yet had a protective effect on 

eczema in the first year of life (Phipatanakul 

et al . 2004) . However, the associations of 

fungi with allergic rhinitis remained essentially 

unchanged when controlling for the presence 

of indoor allergens and endotoxin . 

There is a large literature demonstrating 

the relationship between fungal sensitization 

and allergic rhinitis and asthma, as well as a 

growing literature linking fungal exposure to 

asthma and rhinitis exacerbation (Downs et al . 

2001; Halonen et al . 1997) in sensitized children (Arshad et al . 2001 ; Nolles et al. 2001). 

However, the fact that children with allergic 

rhinitis are sensitized to fungi does not necessarily mean that fungal exposure will lead to 

allergy or allergic symptoms. This study suggests a prospective relationship between exposure and symptoms, although elevation of the 

individual fungal taxa may not lead directly to 

symptom development. For example, relative 

elevation of specific taxa such as Aspergillus, 

Table 1 . Cohort characteristics as predictors of allergic rhinitis . 

Factor No. 

Percent with 

allergic rhinitis HR 95% CI 

Race/ethnicity 

White 309 

African American 46 

Hispanic 18 

Asian 26 

Other 6 

Season of birth 

Winter (December-February) 103 

Spring (March-May) 112 

Summer (June-August) 87 

Fall (September-November) 103 

Sex of child 

Female 195 

Male 210 

Maternal IgE to Alternaria > 0.35 U/mL 

No 316 

Yes 43 

Any LRI in year 1 

No 297 

Yes 108 

Water damage in year 1 

No 263 

Yes 135 

Mold or mildew in year 1 

No 246 

Yes 152 

Water damage or mold 

No 169 

Yes 235 

Abbreviations: -, no data ; LRI, lower respiratory infection . 

*p<0 .05;**p<0.01 . 

12 .0 

21 .7 2.22* 1 .10-4.47 

5.6 0.53 0.07-3.82 

15 .4 1 .37 0.49-3.85 

0 

39 

12 .5 3.33* 1 .10-1012 

13 .6 3 .55* 1 .15-11 .00 

21 .4 5 .76** 1 .99-16 .72 

9.7 

15,7 1 .64 0 .93-2 .88 

11 .4 

25 .6 2 .49** 1 .27-4.89 

10 .8 

18 .5 1 .80* 1 .03-3 .15 

11 .0 

17 .0 1 .59 0 .92-2.74 

11 .8 

15 .1 1 .28 0.74-2.22 

10 .1 

14 .9 1 .46 0.82-2.61 

Table 2 Description of fungi included in the analysis .a 

Fungi No . > 0 90th percentile 

Airborne (cfu/m3 ) 

Aspergillus 253 100 

Cladosporium 315 400 

Nonsporulating 303 278 

Penicillium 346 189 

Yeasts 147 33 

Total airborne 402 1,044 

Dust-borne (cfu/g) 

Alternaria 233 8,333 

Aspergillus 367 33,333 

Aureobasidium 322 24,000 

Cladosporium 343 33,088 

Coelomyces 93 2,941 

Fusarium 49 400 

Nonsporulating 373 38,889 

Penicillium 362 26,087 

Ulocladium 60 435 

Wallemia 61 1,429 

Yeasts 361 58,000 

Zygomycetes 57 909 

Total dust-borne 405 250,000 

'Must have been sampled from the indoor environment 

and have a 90th percentile > 1 cfu . Environmental Health Perspectives " VOLUME 113 1 NUMBER 101 October 2005 1407 
Stark et al . 

Aureobasidium, and yeasts may be a marker for 

overall fungal exposure. In models containing 

the individual taxa and our measure of total 

fungi, total fungi was not predictive of allergic 

rhinitis, suggesting that the combination of 

individual taxa was a better marker of clinically relevant fungal exposure . 

Sensitization to Alternaria, Aspergillus, and 

Penicillium allergens have been suggested as 

being related to allergic rhinitis and asthma 

exacerbation in children (Clark et al . 1999 ; 

Halonen et al . 1997). Purified and characterized allergens have been prepared for 

Aspergillus fumigatus (Asp f 1 and Asp f 3) 

(Macher 2000), which has been shown to 

cause skin reactivity in patients with allergic 

rhinitis (Johnston 2000). However, A. fismigatus was sampled from only three houses . 

The most commonly sampled species in this 

cohort were members of the Aspergillus glaucus group (n = 275) and Aspergillus versicolor 

(n = 255) . Although skin test material is commonly available for both, less is known about 

the allergenicity of these species. A. versicolor 

Table 3. Results of survival analysis of allergic rhinitis . 

High fungi level HR 

Airborne (cfu/m3) 

Aspergillus 1 .09 

Cladosporium 0.72 

Nonsporulating 0.54 

Penicillium 1 .07 

Yeasts 0.98 

Total airborne 0.73 

Dust-borne (cfu/g) 

Alternaria 2.50** 

Aspergillus 2.47** 

Aureobasidium 2.77** 

Cladosporium 1 .63 

Coelomyces 1 .18 

Fusarium 1 .25 

Nonsporulating 2.21* 

Penicillium 1 .34 

Ulocladium 0.82 

Wallemia 2.23* 

Yeasts 2.04* 

Zygomycetes 0.80 

Total dust-borne 2.56** 

'Controlling for water damage or mold or mildew in year 1, African-American ethnicity, maternal Alternaria IgE > 0 .35 U/mL, 

sex, and birth date in fall . *p < 0 .05; **p < 0 .01 . 

Unadjusted 

has been implicated in an outbreak of allergic 

respiratory disease (Jarvis and Morey 2001). 

Cladosporium and Alternaria are known 

sources of allergens, including the proteins 

Alt a 1, Alt a 2, and Cla h 1 (Johnston 2000) . 

Many cross-sectional studies have correlated 

Cladosporium and Alternaria sensitization 

with diagnoses of asthma, eczema, and rhinitis (Arshad et al . 2001; Downs et al . 2001 ; 

Halonen et al . 1997; Nolles et al . 2001) . 

Aureobasidium has been associated with 

hypersensitivity pneumonitis (Greinert et al . 

2000), but its role in the development of allergic rhinitis is unknown. In this study, it may be 

a marker for mold in the home, rather than the 

actual source of the chronic nasal symptoms. 

In their association with chronic nasal 

symptoms, yeasts may also be a marker for 

overall mold exposure, because although they 

have known associations with skin manifestations of allergy, nasal symptoms are less commonly documented. Yeasts are unicellular 

fungi that reproduce primarily by budding 

and, in culture, form pasty colonies similar to 

Adjusted' 

95% CI HR 95% CI 

0.44-2.75 1 .10 0.43-2.80 

0.26-2.00 1 .25 0.43-3.64 

0.17-1.74 0.55 0.17-1.81 

0.42-2.68 0.69 0.23-2.06 

0.36-2.73 079 0.24-2.60 

0.27-2.04 0.83 0.28-2.43 

1 .28-4.86 2.34* 1 .12-4.91 

1 .27-4.81 2.57* 1 .22-5.40 

1 .42-5.39 3.12** 1 .50-6.50 

0.77-3.46 1 .88 0 .81-4.35 

0.51-2.77 0.93 0 .36-2.38 

0.54-2.94 1 .81 0 .76-4.34 

1 .11-4.41 2.45* 1 .15-5.22 

0.57-3.13 1 .51 0 .63-3.64 

0.30-2.28 1 .04 0 .37-2.95 

1 .12-4.45 1 .73 0 .80-3.75 

1 .00-4.19 2.90** 1 .37-6.09 

0.29-2.21 , 0.87 0 .31-2.44 

1 .32-4.98 3.13** 1 .51-6.47 

Table 4. Multivariate Cox regression models of allergic rhinitis . 

Factor 

Model 11 

RR 95% CI 

Water damage or mold/mildew in year 1 

Male sex 

LRI ever in year 1 

Maternal IgE to Alternaria > 0.35 U/mol 

Race Iblack vs . others) 

Season of birth (Sep-Nov vs . others) 

Dust-borne Alternaria 

Dust-borne Aspergillus 

Dust-borne Aureobasidium 

Dust-borne yeasts 

1 .66 

1 .79 

1 .58 

3 07** 

3.82** 

2,44-

1 .40 

3.27** 

3.04** 

2.67* 

0.88-3.15 

0.97-3.29 

0.83-3.02 

1 .49-6.32 

1 .73-8.44 

1 .35-4.42 

0.61-3.23 

1 .50-7.14 

1 .33-6.93 

1 .26-5.66 

Model 2b Model 31 

RR 95% CI RR 95% CI 

1 .77 0.94-334 1 .66 0.87-3.17 

1 .88 * 1 .03-3.42 1 .78 0.97-3.28 

- - 1 .62 0.84-3.12 

2.96** 1 .44-6.09 3.21** 1 .56-6.60 

3.79** 1 .72-8.38 3.27** 1 .51-7.08 

2.46** 1 .35-4.47 2.46** 1 .36-4.48 

1 .52 0.67-3 .44 2.07 0.98-4.37 

2.93** 1 .36-6.30 2.73* 1 .27-5.87 

3.06** 1 .35r6.91 

2.80** 1 .33-5.93 2.52* 1 .18-5.36 

Abbreviations: -, not included ; LRI, lower respiratory infection. 

'Full multivariate model . `Multivariate model omitting any lower respiratory infection in year 1 . 'Multivariate model omitting 

dust-borne Aureobasidium . *p < 0.05 ; **p < 0 .01 . 

those of bacteria (Macher 2000). Several studies have shown that patients with atopic dermatitis and respiratory allergy often develop 

IgE antibodies against yeasts (Devos and Van 

der Valk 2000; Nittner-Marszalska et al . 

2001 ; Tengvall Linder et al . 2000) . One 

showed that patients with atopic dermatitis of 

the head and neck developed IgE antibodies 

against the yeast Pityrosporum ovale much 

more often than did their control group. 

Another found that the enzyme enolase from 

baker's yeast (Saccharomyces cerevisiae) induces 

an immediate dermal allergic reaction in subjects with respiratory allergy and positive skin 

tests to Candida albicans and other fungi . A 

third group demonstrated that Pityrosporum 

orbiculare can induce an eczematous reaction 

in sensitized atopic dermatitis patients. 

Potential study limitations. This study 

does have some limitations . Potential limitations of our work include the relatively small 

sample size, along with the multiplicity of 

variables being considered . Our use of the 

Lasso approach provides an efficient and 

appealing method for handling multiplicity 

issues . The Lasso method is much less prone to 

missing real associations than more traditional 

adjustments for multiple comparisons, such as 

Bonferroni . Even so, the reality is that with 

only 52 cases, some important differences may 

have been missed . It is unlikely, however, that 

our analysis erroneously identified many false 

associations, if any. In addition, because of the 

collinearity of the fungal data and the paucity 

of events, it is difficult to assess the risk of each 

taxon controlling for the others . For example, 

Alternaria is so significantly correlated with 

Aureobasidiunt that its effect is masked when 

both are included in the model. Even still, in a 

combined multivariate model, high levels of 

Aspergillus, Aureobasidium, and yeasts were 

independently associated with an increased risk 

of doctor-diagnosed allergic rhinitis within 

the first 5 years of life . In addition, the air and 

dust samples were single, short-term samples . 

Therefore, it is not clear how representative the 

samples are of long-term household fungal levels . We used only a culture-based analysis to 

determine fungal concentrations, which would 

underestimate actual fungal spore exposures 

and does not account for other fungal agents . 

Also, the culture media used for both the air 

and dust samples, DG18, has high solute concentration, which limits the amount of available water . Thus, some strongly hydrophilic 

fungi (e .g ., Stachybotrys sp ., some yeasts) might 

be underrepresented. In addition, all relationships discussed in this article are related to 

exposures that occurred in the first home in 

which the child lived, and do not account for 

conditions in any subsequent homes or locations where the child may have spent significant time (e.g., a child care center) . Moreover, 

without sampling performed throughout the 

1408 VOLUME 113 1 NUMBER 10 1 October 2005 " Environmental Health Perspectives 
Fungal levels and allergic rhinitis 

study (Chew et al. 2001), it is impossible to 

determine whether high fungal levels early in 

life increase the likelihood of having doctordiagnosed allergic rhinitis later in life, or 

whether the early sampling is representative of 

the environment later in life . In addition, the 

absence of definitive measurements of allergy, 

and the relatively early age of ascertainment of 

outcome in this study such that some children 

may yet develop allergic rhinitis in this cohort, 

may be responsible for the lack of an endotoxin 

effect on the risk of allergic rhinitis in this 

analysis . Further, parental report of allergic 

rhinitis or hay fever was not confirmed by 

chart review, but primary care physician documentation of these diagnoses may not be the 

gold standard because it is likely to vary by 

individual practice. In addition, it is possible 

that the parents did not understand or recall a 

diagnosis of allergic rhinitis . Lastly, without 

skin-prick testing, the possibility exists that 

nasal symptoms related to chronic irritation 

were misdiagnosed as allergic rhinitis by the 

physicians of some of the participating children . Even if fungal exposure in infancy leads 

to allergic rhinitis in some children and to 

chronic irritant nonallergic rhinitis in others, 

these findings still have important public 

health implications . 

Conclusions 

Recently, more attention has been given to the 

need for monitoring of fungal levels and active 

intervention, where necessary Uohnston 2000) . 

Epidemiologic studies have found associations 

between report of home dampness and respiratory symptoms in early life, but most have 

not measured fungi directly and have not 

determined whether fungal effects can be distinguished from other exposures related to 

dampness that prospectively predict respiratory disease. Independent of early life report 

of home dampness, we found that specific 

dust-borne fungi measurable in the home in 

the first 3 months of a child's life was associated with an increased risk of developing 

doctor-diagnosed allergic rhinitis by 5 years 

of age. 

REFERENCES 

Andersen AA . 1958. New sampler for the collection, sizing and 

enumeration of viable airborne particles . J Bacterial 

76:471-484. 

Arshad SH, Tariq SM, Matthews S, Hakim E. 2001 . Sensitization 

to common allergens and its association with allergic 

disorders at age 4 years: a whole population birth cohort 

study. Pediatrics 108:E33-E37. 

Beijer L, Thorn J, Rylander R . 2002 . Effects after inhalation of 

(1 -a 3)-(i-D-glucan and relation to mould exposure in the 

home . Mediators Inflamm 11(31:149-153. 

Camhi SL, Morgan WJ, Pernisco N, Quan SF . 2000. Factors 

affecting sleep disturbances in children and adolescents. 

Sleep Med 1(21 :117-123. 

Celedon JC, Litonjua AA, Weiss ST, Gold DR . 1999 . Day care 

attendance in the first year of life and illnesses of the 

upper and lower respiratory tract in children with a familial 

history of atopy . Pediatrics 10413 pt 11:495-500. 

Chew GL, Burge HA, Dockery DW, Muilenberg ML, Weiss ST, 

Gold DR . 1998. Limitations of a home characteristics questionnaire as a predictor of indoor allergen levels . Am J 

Respir Crit Care Mad 157:1536-1541 . 

Chew GL, Douwes J, Doekes G, Higgins KM, Spithoven J, van 

Strien R et al. 2001 . Fungal extracellular polysaccharides, 

and p (1 -> 3) glucans, and culturable fungi in repeated 

sampling of house dust . Indoor Air 11(3) :171-178 . 

Clark NM, Brown RW, Parker E, Robbins TG, Remick DG, 

Philbert MA, et al . 1999 . Childhood asthma . Environ Health 

Perspect 107(suppl3) :421-429 . 

Carbo GM, Forastiere F, Agabiti N, Plstelli R, Dell'Orco V, Perucci 

CA, et al. 2001 . Snoring in 9-to 15-year old children : risk factors and clinical relevance . Pediatrics 108(5) :1149-1154. 

Daisey JIM, Angell WJ, Apte MG . 2003 . Indoor air quality, ventilation and health symptoms in schools : an analysis of 

existing information . Indoor Air 13:53-64. 

Devos SA, Van der Valk PG . 2000 . The relevance of skin prick 

testing for Prtyrosporum ovale in patients with head and 

neck dermititis. Allergy 55(11) :1056-1058 

Dotterud LR, Vorland LH, Falk ES . 1996 . Mould allergy in school 

children in relation to airborne fungi and residential characteristics in homes and schools in northern Norway. 

Indoor Air 6 :71-76 . 

Downs SH, Mitakakis TZ, Marks GB, Car NG, Belousova EG, 

Leuppi JD, et al . 2001 . Clinical importance of Alternaria exposure in children. Am J Respir Crit Care Med 164(31:455-459 . 

Ellis MB. 1971 . Dematiaceous Hyphomycetes . Kew, Surry, 

UK:Commanwealth Mycological Institute . 

Gent JF, Ran P, Belanger K, Triche E, Bracken MB, Holford TR, 

et al. 2002. Levels of household mold associated with respiratory symptoms in the first year of life in a cohort at risk 

for asthma . Environ Health Perspect 110 :A781-A786 . 

Gold DR, Burge HA, CareyV, Milton DK, Platts-Mills T, Weiss ST. 

1999. Predictors of repeated wheeze in the first year of life . 

Am J Respir Crit Care Mad 160 :227-236. 

Greinert U, Lapp U, Becker W. 2000. Bird keeper's lung without 

bird keeping . Eur J Mad Res 5(3) :124. 

Halonen M, Stern DA, Wright AL, Taussig LM, Martinez FD . 

1997. Alternaria as a major allergen for asthma in children 

raised in a desert environment. Am J Respir Crit Care Med 

155 :1356-1361 . 

Hastie TJ, Tibshirani RJ . 1990 . Generalized Additive Models. 

London :Chapman and Hall . 

International Study of Asthma and Allergies in Childhood 

(ISAAC) Steering Committee . 1998 . Worldwide variation in 

prevalence of symptoms of asthma allergic rhinoconjunctivitis, and atopic eczema : ISAAC . Lancet 351 :1225-1232 . 

Jarvis JQ, Morey PR . 2001 . Allergic respiratory disease and 

fungal remediation in a building in a subtropical climate. 

Appl Occup Environ Hyg 16(3) :380-388. 

Johnston RB, ad. 2000. Clearing the Air : Asthma and Indoor Air 

Exposures . Washington, DC :National Academy Press . 

Kapsali T, Horowitz E, Diemer F, Togas A . 1997 . Rhinitis is ubiquitous in allergic asthmatics . J Allergy Clin Immunol 

99:S138. 

Kilpelainen M, Terho E0, Helenius H, Koskenvuo M . 2001 . 

Home dampness, current allergic diseases, and respiratory infections among young adults. Thorax 56 :462-467 . 

Litonjua AA, Carey VJ, Burge HA, Weiss ST, Gold DR . 1998 . 

Parental history and the risk of childhood asthma . Does 

mother confer more risk than father? Am J Respir Crit 

Care Mad 158(1) :176-181 . 

Macher J, ad . 2000 . Bioaerosols : Assessment and Control . 

Cincinnati, OH :American Conference of Government 

Industrial Hygienists Bioaerosols Committee . 

Nittner-Marszalska M, Wojcicka-Kustrzeba I, Bogacka E, 

Patkowski J, Dobek R . 2001 . Skin prick test response to 

enzyme enolase of the baker's yeast (Saccharomyces 

cerevisiae) in diagnosis of respiratory allergy. Mad Sci 

Monit 7(1):121-124 . 

Nolles G, Hoekstra M0, Schouten JP, Gerritsen J, Kauffman 

HF . 2001 . Prevalence of immunoglobulin E for fungi in 

atopic children . Clin Exp Allergy 31 :1564-1570. 

Park JH, Gold DR, Spiegelman DL, Burge HA, Milton DK. 2001 . 

House dust endotoxin and wheeze in the first year of life . 

Am J Respir Crit Care Med 163 :322-328 . 

Phipatanakul W, Celedon JC, Raby BA, Litonjua AA, Milton DK, 

Sredl D, et a1.2004. Endotoxin exposure and eczema in the 

first year of life. Pediatrics 114:13-18 . 

Scharf MB, Cohen AP . 1998 . Diagnostic and treatment implications of nasal obstruction in snoring and obstructive sleep 

apnea . Ann Allergy Asthma Immunol 81(4):279-287. 

Scheel CM, Rosing WC, Farone AL . 2001 . Possible sources of 

sick building syndrome in a Tennessee middle school . 

Arch Environ Health 56(5):413-117. 

Skoner DP . 2001 . Allergic rhinitis : definition, epidemiology, 

pathophysiology, detection, and diagnosis . J Allergy Clin 

Immunal 108:S2-S8. 

Stark PC, Burge HA, Ryan LM, Milton DK, Gold DR . 2003. Fungal 

levels in the home and lower respiratory tract illnesses in 

the first year of life . Am J Respir Crit Care Med 168 :232-237. 

Tengvall Linder M, Johansson C, Scheynius A, Wahlgren C . 

2000 . Positive atopy patch test reactions to Pityrosporum 

orbiculare in atopic dermatitis patients. Clin Exp Allergy 

30(1):122-131 . 

Tibshirani R. 1997 . The Lasso method for variable selection in 

the Cox model . Statist Med 16 :385-395 . 

Verhoeff AP, van Reenen-Hoekstra ES, Samson RA, Brunekreef B, 

van Wijnen JH . 1994 Fungal propagules in house dust . I . 

Comparison of analytic methods and their value as estimators of potential exposure. Allergy 49(7):533-539. 

van Arx JA. 1970 . The Genera of Fungi Sporulating in Pure 

Culture . Lehre, Germany:Verlag von J Cramer . 

Environmental Health Perspectives " VOLUME 113 1 NUMBER 10 1 October 2005 1409