Indoor Mold: Better Coordination of Research on Health Effects and More Consistent Guidance Would Improve Federal Efforts
Published: 2008-09-30T00:00:00

Fast Facts:

Highlights:
section_title: Why GAO Did This Study
paragraphs: Recent research suggests that indoor mold poses a widespread and, for some people, serious health threat. Federal agencies engage in a number of activities to address this issue, including conducting or sponsoring research. For example, in 2004 the National Academies' Institute of Medicine issued a report requested by the Department of Health and Human Services (HHS) summarizing the scientific literature on mold, dampness, and human health. In addition, the Federal Interagency Committee on Indoor Air Quality supports the Environmental Protection Agency's (EPA) indoor air research program. With respect to the health effects of exposure to indoor mold, GAO was asked to report on (1) the conclusions of recent reviews of the scientific literature, (2) the extent to which federal research addresses data gaps, and (3) the guidance agencies are providing to the general public. GAO reviewed scientific literature on indoor mold's health effects, surveyed three agencies that conduct or sponsor indoor mold research, and analyzed guidance issued by five agencies.
section_title: What GAO Found
paragraphs: In general, the Institute of Medicine's 2004 report, and reviews of the scientific literature published from 2005 to 2007 that GAO examined, concluded that certain adverse health effects are more clearly associated with exposure to indoor mold than others. For example, the Institute of Medicine concluded that some respiratory effects, such as exacerbation of pre-existing asthma, are associated with exposure to indoor mold but that the available evidence was not sufficient to determine whether mold and a variety of other health effects, such as the development of asthma, cancer, and acute pulmonary hemorrhage in infants, are associated. While the reviews GAO examined generally agreed with these conclusions, a few judged the evidence for some health effects as somewhat stronger. For example, the American Academy of Pediatrics concluded in 2006 that a plausible link exists between acute pulmonary hemorrhage in infants and exposure to toxins that some molds produce. In addition, the 2004 Institute of Medicine report identified the need for additional research to address a number of data gaps related to the health effects of indoor mold. The 65 ongoing federal research activities on the health effects of exposure to indoor mold conducted or sponsored by EPA, HHS, and the Department of Housing and Urban Development (HUD) address to varying extents 15 gaps in scientific data reported by the Institute of Medicine. For example, many of the research activities address data gaps related to asthma and measurement methods, while other data gaps, such as those related to toxins produced by some molds, are being minimally addressed. Further, less than half of the ongoing mold-related research activities are coordinated either within or across agencies. This limited coordination is important in light of, among other things, the wide range of data gaps identified by the Institute of Medicine and limited federal resources. The Federal Interagency Committee on Indoor Air Quality could provide a structured mechanism for coordinating research activities on mold and other indoor air issues by, for example, serving as a forum for reviewing and prioritizing agencies' ongoing and planned research. However, it currently does not do so. Despite limitations of scientific evidence regarding a number of potential health effects of exposure to indoor mold, enough is known that federal agencies have issued guidance to the general public about health risks associated with exposure to indoor mold and how to minimize mold growth and mitigate exposure. For example, guidance issued by the Consumer Product Safety Commission, EPA, the Federal Emergency Management Agency, HHS, and HUD cites a variety of health effects of exposure to indoor mold but in some cases omits less common but serious effects. Moreover, while guidance on minimizing indoor mold growth is generally consistent, guidance on mitigating exposure to indoor mold is sometimes inconsistent about cleanup agents, protective clothing and equipment, and sensitive populations. As a result, the public may not be sufficiently advised of indoor mold's potential health risks.

section_title: Letter
paragraphs: Mold is a general term for certain microorganisms that thrive in damp  Mold is a general term for certain microorganisms that thrive in damp  conditions and are regularly found in indoor air and on materials and  conditions and are regularly found in indoor air and on materials and  surfaces, such as walls. While indoor mold was considered largely a  surfaces, such as walls. The presence of moisture is the primary factor  serious health threat. A variety of health effects have been directly linked to  contamination.”
In this report, we use the term “mold” to refer to the large number of species of fungi.
National Institute of Environmental Health Sciences, “A Spreading Concern: Inhalational  Health Effects of Mold,” Environmental Health Perspectives (June 2007).
Department of Health and Human Services, Centers for Disease Control and Prevention,  Mold Prevention Strategies and Possible Health Effects in the Aftermath of Hurricanes  and Major Floods (Atlanta, 2006). gases that often create a musty odor, and toxins released by certain types  of mold under certain conditions—can also cause disease. An example of  a toxin-producing mold is Stachybotrys chartarum, which produces  multiple toxins that may suppress the functioning of immune cells.
Mold may affect human health through a number of routes and  mechanisms. While inhalation is generally the most common route of  exposure for mold in indoor environments, exposure can also occur  through ingestion (for example, hand-to-mouth contact) and contact with  the skin. The roles of these routes of exposure in causing illness are  unclear. Once exposure occurs, health effects may arise through several  potential mechanisms, including allergic (or immune-mediated),  infectious, and toxic. It is not always possible to determine which of these  mechanisms is associated with a specific health outcome.
Although federal agencies are engaged in a number of efforts to address  indoor mold, there are no federal or generally accepted health-based  standards for safe levels of mold in the air or on surfaces. According to  EPA officials, the lack of federal regulation of airborne concentrations of  mold indoors is largely due to the insufficiency of data needed to establish  a scientifically defensible health-based standard. Another factor is the lack  of scientific consensus regarding how best to measure these  concentrations. The presence of mold in homes and workplaces has led to  numerous lawsuits. For example, highly publicized cases involving mold  include a Texas homeowner’s successful multi-million-dollar lawsuit  against an insurance company related to mold contamination. Moreover,  mold contamination at the Walter Reed Army Medical Center, where  soldiers returning from Iraq are being treated, received significant media  coverage.
In 2001, recognizing the need for credible and comprehensive information  on the health effects of exposure to indoor mold, HHS commissioned the  National Academies’ Institute of Medicine to review the available scientific  literature on the links among mold, dampness, and human health. In 2004,  the Institute of Medicine issued its report, which made a variety of  recommendations for research aimed at better understanding the health  risks of exposure to indoor mold. Currently, a number of federal agencies  conduct mold-related research or provide guidance to the public on health  effects associated with exposure to mold and on ways to mitigate such  exposure. These federal agencies include the Environmental Protection  Agency (EPA); the Department of Housing and Urban Development  (HUD); the Consumer Product Safety Commission; the Federal Emergency  Management Agency (FEMA); and HHS and a number of its entities, such  as CDC and the National Institutes of Health (NIH). In 1983, a  congressional committee directed the establishment of the Federal  Interagency Committee on Indoor Air Quality to coordinate federal indoor  air quality research. The research on indoor mold is a small component of  indoor air research activities, and it is conducted or sponsored by a  number of different entities within and across agencies. EPA serves both  as the executive secretary of the interagency committee and as a co-chair;  other federal departments and agencies participate as co-chairs and  members.
You asked us to determine (1) what recent reviews of scientific literature  have concluded about the health effects of exposure to indoor mold; (2)  the extent to which federal research addresses data gaps related to the  health effects of exposure to indoor mold; and (3) the guidance key federal  agencies are providing to the general public on the health risks of  exposure to mold, minimizing mold growth, and mitigating exposure to  mold, and the extent to which the guidance is consistent. For the first  objective, we analyzed the 2000 and 2004 Institute of Medicine reports,  Clearing the Air: Asthma and Indoor Air Exposures and Damp Indoor  Spaces and Health. We also analyzed 20 reviews of the scientific literature  on the health effects of exposure to indoor mold that were published from  2005 to 2007; we did not review individual studies. To obtain information  on federal research related to the health effects of exposure to indoor  mold, we conducted two surveys of officials at EPA, HHS, and HUD from  November 2007 to May 2008. We focused on these agencies because of  their past and current research activities on the health effects of mold. We  used one survey to (1) identify research activities related to the health  effects of indoor mold ongoing as of October 1, 2007, and (2) determine  the extent to which these research activities address the 15 data gaps  identified in the 2000 and 2004 Institute of Medicine reports related to the  health effects of exposure to indoor mold. We also used this survey to  identify the extent to which these activities were coordinated both within  and across agencies. We conducted a second survey of these agencies to  collect basic information regarding their mold-related research activities  completed from January 1, 2005, to September 30, 2007. Overall, we  received information on 107 research activities from 37 EPA, HHS, and  HUD officials. Summaries of the research activities conducted or  sponsored by EPA, HHS, and HUD are provided in a supplement to this  report (see GAO-08-984SP). We also examined the extent to which the  Federal Interagency Committee on Indoor Air Quality has been used to  coordinate federal research activities related to the health effects of  exposure to indoor mold. To evaluate guidance documents issued to the  public by federal agencies, we focused on the five federal agencies  primarily responsible for providing information to the general public on  health risks and minimizing and mitigating exposure to contaminants,  including mold—the Consumer Product Safety Commission, EPA, FEMA,  HHS, and HUD. Our review focuses on the health effects and guidance to  the general public related to indoor mold in homes and does not address  occupational exposures or technical guidance documents targeted to  specialized audiences such as medical professionals. Appendix I provides  a more detailed description of our scope and methodology. We conducted  this performance audit from January 2007 to September 2008 in  accordance with generally accepted government auditing standards. Those  standards require that we plan and perform the audit to obtain sufficient,  appropriate evidence to provide a reasonable basis for our findings and  conclusions based on our audit objectives. We believe that the evidence  obtained provides a reasonable basis for our findings and conclusions  based on our audit objectives.
subsections: section_title: Background
paragraphs: Moisture is the primary factor leading to indoor mold growth. To grow  indoors, mold also needs temperatures above freezing levels—from 32 to  130 degrees Fahrenheit—and organic matter. The nutrients upon which  mold feeds are provided by house dust and many surface and construction  materials, such as wallpapers, textiles, wood, paints, and glues. Because  the appropriate temperature and necessary nutrients are common in  homes, mold growth can rapidly occur indoors when excessive moisture  or water accumulates as a result of, for example, floods and other natural  disasters; building design or construction flaws; and poor building  maintenance practices, such as not repairing leaking plumbing. Moist  conditions indoors may also foster the growth of other organisms capable  of causing adverse health effects, including bacteria, cockroaches, and  dust mites.
Mold growth may be particularly severe following natural disasters such as  hurricanes and flooding. The extent of the flooding after Hurricanes  Katrina and Rita in 2005 led to conditions supporting widespread mold  growth. Unlike other hurricane-impacted areas, where residents could  access their buildings relatively quickly after the flood event, many  residents in New Orleans were unable to access buildings for several  weeks because of prolonged flood inundation. According to a CDC survey,  an estimated 46 percent of homes in New Orleans and surrounding areas  had visible mold growth. Widespread indoor mold contamination can  cause adverse health effects in returning residents and make it more  difficult to rehabilitate houses for reoccupation. For example, in 2006 the  Army Corps of Engineers noted that because of mold problems caused by  the extensive flooding, many residences that did not require demolition  would nonetheless need to be gutted—stripping the walls down to the  studs—before they could be renovated.
The Institute of Medicine has identified four possible levels of connection  between indoor mold and adverse health effects: sufficient evidence of a  causal relationship, sufficient evidence of an association, limited or  suggestive evidence of an association, and inadequate or insufficient  evidence to determine whether an association exists. According to HHS,  establishing a causal relationship with adequate certainty requires several  types of evidence, including (1) epidemiologic associations, (2)  experimental exposure in animals or humans that leads to the symptoms  and signs of the disease in question, and (3) reduction in exposure that  leads to reduction in the symptoms and signs of the disease. HHS officials  said that more data are needed to establish a causative association  between exposure to mold and some illnesses because the vast majority of  the studies conducted to date have been only epidemiologic.
The federal government has responded to the uncertainty surrounding the  health effects of exposure to indoor mold by, among other things,  sponsoring reviews of the available scientific evidence. Committees of the  National Academies’ Institute of Medicine have produced two reports in  the past several years that relate to the health effects of exposure to  indoor mold. For a 2000 report requested by EPA, Clearing the Air:  Asthma and Indoor Air Exposures, the Institute of Medicine assembled a  multidisciplinary committee to examine the relevant research pertaining to  asthma and the indoor environment, including, among many other issues,  the possible impact of indoor mold on asthma prevalence. For its 2004  report requested by the CDC, Damp Indoor Spaces and Health, another  Institute of Medicine committee reviewed the scientific literature to  determine the connections among damp indoor spaces, microorganisms  such as mold, and a variety of human health effects. This committee used  a uniform set of categories to summarize its conclusions regarding the  evidence of association between various health outcomes and exposure to  indoor dampness or the presence of mold or other agents in damp indoor  environments. While research in this field continues to evolve, both  reports made recommendations for additional research related to mold  and other areas that remain relevant—that is, the data gaps have not been  resolved.
In addition to sponsoring reviews of the available scientific evidence,  federal agencies have the opportunity to share information on various  aspects of indoor air quality, including mold, through the Federal  Interagency Committee on Indoor Air Quality. Title IV of the Superfund  Amendments and Reauthorization Act of 1986 directed EPA, among other  things, to disseminate the results of its indoor air quality research program  and establish an advisory committee consisting of other federal agencies.  EPA serves as the executive secretary of the Federal Interagency  Committee on Indoor Air Quality, which fulfills this advisory role. The  committee is co-chaired by EPA, the Department of Energy (DOE), the  Consumer Product Safety Commission, the National Institute for  Occupational Safety and Health (NIOSH), and the Occupational Safety and  Health Administration (OSHA). Other federal departments and agencies  participate in the committee as members. In 1991, we recommended that  the Administrator, EPA, work with other members of the committee to  clearly define in a charter the roles and responsibilities of the agencies  participating in the committee in order to strengthen interagency  coordination of indoor air research. However, EPA has not implemented  this recommendation.
Although federal agencies are engaged in a number of efforts to address  indoor mold, there are no federal or generally accepted health-based  standards for safe levels of mold, its components, or its products in the air  or on surfaces. In fact, neither EPA nor OSHA has established health- based standards for airborne concentrations of mold or mold spores  indoors. Similarly, NIOSH has not set recommended exposure limits for  indoor mold or mold spores. Further, according to EPA officials, the lack  of federal regulation of airborne concentrations of mold indoors is largely  attributable to the insufficiency of data needed to establish a scientifically  defensible health-based standard. EPA officials also emphasized that the  agency lacks the authority to establish airborne concentration limits for  mold indoors. Legislation to require EPA to take action with respect to  indoor mold has been introduced in Congress in the past but was not  enacted. For example, the proposed United States Toxic Mold Safety and  Prevention Act, most recently introduced in Congress in 2005, would have  directed EPA to promulgate standards for preventing, detecting, and  remediating indoor mold growth, among other things.
The presence of mold in homes and workplaces has led to numerous  lawsuits alleging personal injury or property damage. To obtain a  judgment that mold has caused personal injury, an individual must  persuade the court that the type of mold at issue is capable of causing the  individual’s condition and that the mold actually caused the condition in  the specific case. Litigants generally use expert witness testimony in an  attempt to prove or disprove these points in court. Courts use different  standards to judge whether such testimony is admissible. In some states,  courts will admit such testimony only if it is in accord with generally  accepted consensus of the relevant scientific community. In other states  and in the federal courts, judges independently evaluate the reliability of  the evidence by weighing several factors, only one of which focuses on the  views of the relevant scientific community. Many state courts use a  mixture of these two methods.
Insurance companies are frequently defendants in mold litigation, and in  response to the rise in cases early in the decade, many began changing  their policies to specifically exclude mold-related injuries and property  damage from coverage. For example, many insurance policies now contain  language stating that the insurance company “will not pay for loss or  damage caused by or resulting from ... rust, corrosion, fungus, decay,” and  other conditions. As of 2006, the insurance regulatory agencies in 40 states  had approved mold-related exclusions.
Partly in response to a significant increase in mold litigation in the early  part of this decade, states began enacting legislation to address various  aspects of the mold problem. For example, in 2001 California enacted the  Toxic Mold Protection Act, which requires the state’s Department of  Health Services to establish permissible mold exposure limits for indoor  air. In addition, in 2003, Texas passed legislation requiring a mold  remediation contractor to certify to a homeowner that the mold  contamination identified for the project had been remediated as outlined  in the mold management plan or remediation protocol. Further, the Texas  law requires owners selling property to provide buyers with copies of each  mold remediation certificate issued for the properties the 5 preceding  years. Examples of other state legislative responses to mold issues include  laws  requiring landlords to disclose to tenants information about the health  hazards associated with exposure to indoor mold;   prohibiting litigation against a real estate agent acting on behalf of a buyer  or seller who has truthfully disclosed any known material defects;    establishing licensing requirements for individuals involved with mold  assessment and remediation; and   creating a group to study the effects of toxic mold.
section_title: Many Studies Associate Indoor Mold with Adverse Health Effects but Cite the Need for Additional Research
paragraphs: While the 2004 Institute of Medicine report, and reviews of the scientific  literature published subsequently, have found evidence associating indoor  mold with certain adverse health effects, the evidence supporting an  association between mold and other health effects remains less certain.  Two factors, in particular, pose challenges for those attempting to  determine the health effects of exposure to indoor mold: valid quantitative  methods of measuring exposure are lacking, and a wide variety of other  potential disease-causing agents are likely to be present in damp indoor  environments, along with mold. According to the Institute of Medicine and  recent reviews of the scientific literature, further research is required to  advance the understanding of the relationships between dampness, indoor  mold, and human health.
subsections: section_title: While Mold Is Associated with Certain Adverse Health Effects, Evidence for Others Is Less Certain
paragraphs: The 2004 Institute of Medicine report, Damp Indoor Spaces and Health,  found sufficient evidence of an association between exposure to indoor  mold and certain adverse health effects—that is, an association between  the agent and the outcome has been observed in studies in which chance,  bias, and confounding factors can be ruled out with reasonable  confidence. These health effects include    upper respiratory tract symptoms, including nasal congestion, sneezing,  runny or itchy nose, and throat irritation;   exacerbation of pre-existing asthma;    hypersensitivity pneumonitis in susceptible persons; and  fungal colonization or opportunistic infections in immune-compromised  persons.
Of these health effects, the upper respiratory tract symptoms associated  with allergic rhinitis are the most common, according to the American  Academy of Pediatrics. In addition, the association between indoor mold  and exacerbation of asthma symptoms is a particularly significant public  health concern because asthma is the most common chronic illness among  children in the United States and one of the most common chronic  illnesses overall, according to the Institute of Medicine’s 2000 report,  Clearing the Air: Asthma and Indoor Air Exposures. Importantly, mold  can affect certain populations disproportionately. For example, the 2004  Institute of Medicine report found sufficient evidence of an association  between exposure to the mold genus Aspergillus and serious respiratory  infections in people with severely compromised immune systems (such as  chemotherapy patients and organ transplant recipients). This report also  found sufficient evidence of an association between exposure to indoor  mold and hypersensitivity pneumonitis—a relatively rare but potentially  serious allergic reaction—in susceptible persons. In addition to these  more established health effects, this report also found limited or  suggestive evidence of an association between indoor mold and lower  respiratory illness (for example, bronchitis and pneumonia) in otherwise  healthy children.
Most of the 20 reviews of the scientific literature published from 2005 to  2007 that we examined generally agreed with the conclusions of the 2004  Institute of Medicine report. However, two of the reviews characterized  the relationship between exposure to indoor mold and certain of the above  health effects more strongly. The American Academy of Pediatrics stated  in its 2006 report that epidemiologic studies consistently support causal  relationships between exposure to mold and upper respiratory tract  symptoms and exacerbation of pre-existing asthma. The American  Academy of Pediatrics also said that epidemiologic studies support a  causal relationship between exposure to mold and hypersensitivity  pneumonitis in susceptible persons. Moreover, a 2007 meta-analysis  sponsored by EPA and DOE found that building dampness and mold are  associated with increases of 30 percent to 50 percent in a variety of health  outcomes, such as upper respiratory tract symptoms, wheeze, and cough.  The authors concluded that these associations strongly suggest these  adverse health effects are caused by dampness-related exposures.
According to the 2004 Institute of Medicine report, the evidence of an  association between exposure to indoor mold and a variety of other health  effects, however, is inadequate or insufficient—that is, the available  studies are of insufficient quality, consistency, or statistical power to  permit a conclusion regarding the presence of an association. The health  effects for which there is inadequate or insufficient evidence of an  association with indoor mold include    acute idiopathic pulmonary hemorrhage in infants;    airflow obstruction in otherwise-healthy persons;    cancer;    chronic obstructive pulmonary disease;  inhalation fevers not related to occupational exposures;  lower respiratory illness in otherwise-healthy adults;   mucous membrane irritation syndrome;  rheumatologic and other immune diseases;    shortness of breath; and    skin symptoms.
Most of the recent reviews of the literature we examined generally  concurred with these Institute of Medicine conclusions as well, although a  few found a somewhat stronger relationship between indoor mold and  certain of the health effects listed above. For example, a 2007 review  concluded that dampness and exposure to indoor mold can exacerbate or  may cause shortness of breath, among other health effects. In addition,  other reviews differed in their conclusions regarding the link between  exposure to indoor mold and acute idiopathic pulmonary hemorrhage in  infants, the sudden onset of pulmonary hemorrhage in a previously healthy  infant. This condition was reported among a group of infants from the  same part of Cleveland, Ohio, in the 1990s and attributed by some  researchers to exposure to indoor mold. Five of the reviews we examined  contained conclusions about acute idiopathic pulmonary hemorrhage in  infants and children. Two concluded that mold has not been proven to  cause this condition. However, a third review—the American Academy of  Pediatrics 2006 report—said that although a causal relationship has not  been firmly established, a variety of studies have provided some evidence  that such a relationship is plausible. The fourth review said that the  association between acute idiopathic pulmonary hemorrhage in infants  and children and mold is strong enough to justify removing them from  moldy environments or cleaning up these spaces, and the fifth review  reiterated this recommendation.
Some of the health effects for which the evidence remains unclear (for  example, fatigue and acute idiopathic pulmonary hemorrhage in infants)  have been attributed to reactions to toxins, or “mycotoxins,” that can be  produced by certain types of mold that grow indoors. The reviews we  examined were largely consistent in their interpretations of the evidence  for the role of mycotoxins in relation to adverse health effects. The  Institute of Medicine reported in 2004 that (1) exposure to mycotoxins can  occur via inhalation, contact with the skin, and ingestion of contaminated  food and (2) research on Stachybotrys chartarum (a species of indoor  mold that can produce mycotoxins) suggests that effects in humans may  be biologically plausible. However, the report also noted that the effects of  chronic inhalation of mycotoxins require further study and that additional  research must confirm the observations on Stachybotrys chartarum  before a more definitive conclusion can be drawn. Among the more recent  reviews we examined that specifically addressed mycotoxins, five reached  a similar conclusion—that is, that the current evidence is inconclusive or  limited. However, one review suggested that it is likely that mycotoxins  play some role in building-related disease, including exacerbation of pre- existing asthma. On the other hand, another recent review cast doubt on  the health effects of mycotoxins in one set of circumstances—specifically,  the review concluded that it was improbable for mycotoxins to cause  negative health effects through a toxic mechanism when individuals inhale  mycotoxins in nonoccupational settings (such as homes). This review,  however, explicitly stated this conclusion did not address adverse health  effects of mycotoxins that may be caused by immune-mediated  mechanisms or stem from exposure in occupational settings or by  ingestion.
section_title: Two Key Factors Pose Challenges for Determining the Health Effects of Exposure to Indoor Mold
paragraphs: According to the 2004 Institute of Medicine report, two key issues largely  contribute to the scientific data gaps regarding the relationship between  mold and adverse health effects: (1) valid quantitative methods of  measuring exposure are lacking, and (2) a wide variety of potential  disease-causing agents are likely to be present in damp indoor  environments, which makes it difficult to link health effects with specific  agents. Without standardized, quantitative methods to measure exposure,  it is difficult to compare exposure levels across studies or between  individuals with and without symptoms of adverse health effects. This  makes it challenging to draw valid and consistent conclusions on the  health effects of indoor mold.
No single or standardized method to measure the magnitude of exposure  to mold has been developed. Consequently, researchers use a variety of  methods to assess exposure, each of which has advantages and  disadvantages. For example, most studies use an indirect method to assess  exposure—occupant questionnaires about the presence of dampness or  mold in a building—according to the 2004 Institute of Medicine report.  Other exposure assessment methods include personal monitoring, which  involves measuring agent concentrations with monitors carried by  individuals, and quantifying biologic response markers in bodily fluids.  Another method of exposure assessment is to collect environmental  samples of indoor air, dust, or building materials such as wallboard and  quantitatively analyze the presence of mold (or its components or  products) in the samples. In addition to the various methods that can be  used to collect and analyze samples, environmental sampling for mold is  complicated by the fact that concentrations of mold (particularly in the  air) can vary over time and across an indoor environment. Moreover, many  newly developed sampling methods are not commercially available or  well-validated.
The second issue contributing to limitations in the understanding of the  relationship between mold and a number of adverse health effects is the  variety of potential disease-causing agents—including many species of  mold and other biological agents, such as bacteria or dust mites—that are  likely to be present in damp indoor environments. The number of such  agents makes it difficult to know which ones are specifically responsible  for the adverse health effects attributed to these environments. For  example, of the approximately 1 million species of mold, there are about  200 species of mold to which humans are routinely exposed, although not  all of these are commonly identified in indoor environments, and not all  types pose the same hazards to human health. The mold genus Alternaria,  for instance, which has been found in moldy building materials, has been  linked to severe asthma. Furthermore, several different components or  products of mold, such as mycotoxins, may function as disease-causing  agents in indoor environments. The release of these mold components or  products varies with environmental and other factors, and the individual  roles they may play in adverse health effects are not fully understood.  People are also exposed to mold in outdoor environments, where the  concentrations, while they vary considerably, are usually higher than those  found indoors. While the specific species of mold that grow indoors may  differ from those found outdoors, the potential for outdoor exposure  further complicates efforts to determine the relationship between adverse  health effects and indoor exposure to mold.
In addition to mold, damp indoor areas can support other biological agents  that may result in adverse health effects, including bacteria, dust mites,  cockroaches, and rodents. Dust mites, for example, are known to cause  the development of asthma. Damp conditions may also lead to potentially  harmful chemical emissions from building materials and furnishings. For  example, excessive indoor humidity may increase the release of  formaldehyde, a probable human carcinogen, from building materials such  as particle board. Exposure to formaldehyde has been linked to some of  the same health effects that have been attributed to indoor mold, such as  wheezing, coughing, and exacerbation of asthma symptoms, as well as  more severe effects.
section_title: Additional Research Is Needed to Better Address Uncertainties Related to the Connection between Health Effects and Exposure to Indoor Mold
paragraphs: The 2000 and 2004 Institute of Medicine reports and other recent reviews  of the scientific literature have identified numerous areas where further  research is required to advance the understanding of the relationships  between dampness, indoor mold, and human health. Specifically, the  health effects of the components and products of mold require further  study. The effects of mycotoxins in particular remain poorly understood,  partly because most of the toxicologic studies on mycotoxins have  examined the acute (or short-term) effects of high levels of exposure to  mycotoxins in small populations of animals. To address these limitations,  the 2004 Institute of Medicine report recommended that studies be  conducted to help determine, among other things, (1) the effects of  chronic (or long-term) exposures to mycotoxins via inhalation and (2) the  dose of mycotoxins required to cause adverse health effects in humans.  This report also recommended research on a particular species of toxin- producing mold, Stachybotrys chartarum, and on the relationship  between mold and dampness and acute idiopathic pulmonary hemorrhage  in infants. In its 2000 report, the Institute of Medicine also called for  additional research related to mold particles as allergens and research to  evaluate the association of dampness and mold with the development of  asthma. As can be expected as research progresses over time, some of the  more recent reviews we examined made additional or more specific  research recommendations related to mycotoxins and other components  and products of mold. A number of lawsuits alleging serious health effects  as a result of exposure to indoor mold have involved exposure to  mycotoxins, underscoring the need for additional research in this area.
In addition, research to develop, improve, and standardize methods for  assessing exposure to mold is a high priority for understanding the health  effects of mold, according to the Institute of Medicine’s 2004 report.  Specifically, the report recommends additional research to validate and  refine existing exposure assessment methods for mold, including  procedures for collecting and analyzing environmental samples. Such  research would facilitate comparison of results within and across  epidemiological studies and help better define the relationships between  mold and adverse health effects. In addition, improved methods for  measuring exposure to specific components of mold would help efforts to  study the roles of these agents in causing adverse health effects.
The 2004 Institute of Medicine report also identified the need for  additional research on mold mitigation strategies and measures to prevent  or reduce dampness, the growth of indoor mold, and exposure to mold.  These strategies could include remediation activities, building renovation,  and changes in building operation or maintenance practices. For example,  research is needed to develop standardized, effective cleanup methods to  mitigate mold growth after flooding and other catastrophic water events.  In addition, the 2004 Institute of Medicine report recommended research  to assess how effectively personal protective equipment, such as gloves,  safety goggles, and respirators, reduces exposure to mold during  mitigation activities. Research in these areas is important to help ensure  that (1) mold mitigation actually improves unhealthy conditions in indoor  environments and (2) protective equipment used during remediation  successfully reduces the amount of mold to which workers and building  occupants are exposed.
section_title: Federal Research Activities on the Health Effects of Indoor Mold Address Data Gaps to Varying Degrees; Limited Planning and Coordination of the Activities May Reduce Their Ability to Close Data Gaps
paragraphs: Federal research activities address gaps in scientific data on the health  effects of indoor mold identified by the Institute of Medicine to varying  degrees, with a large number focusing on two areas in particular—asthma  and measurement methods. The impact of this research portfolio may be  reduced, however, by limited planning and coordination.
subsections: section_title: Federal Research Activities on Mold Largely Address Asthma and Measurement Methods
paragraphs: EPA, HHS, and HUD officials reported that they were conducting or  sponsoring 65 mold research activities as of October 1, 2007: HHS reported  43 ongoing research activities; and EPA and HUD reported 15 and 7,  respectively. The Institute of Medicine’s 2000 and 2004 reports identified a  number of gaps in the research needed to more clearly delineate any  association between exposure to indoor mold and a number of adverse  health effects. As shown in appendix III, these gaps may be grouped into  15 broad categories. Agency officials reported that most of the individual  federal research activities address 2 or more of the 15 data gaps.  Collectively, the agencies indicated that their research activities address  all of the 15 data gaps to varying extents—the number of research  activities addressing individual gaps ranged from 1 to 32 (see app. III).  Moreover, EPA, HHS, and HUD officials reported that 75 percent of their  mold research activities address at least one of five particular data gaps— three of which relate to asthma, and two of which relate to sampling and  measurement methods. These five data gaps are as follows:  Identify environmental factors that either lead to the development of  asthma or precipitate symptoms in subjects who already have asthma  using good measures of fungal exposure.
Determine the association of dampness problems with asthma  development and symptoms by researching the causative agents (e.g.,  molds, dust mite allergens) and documenting the relationship between  dampness and allergen exposure.
Advance the understanding of specific bioaerosols (small airborne  particles) in relation to asthma by studying the epidemiology of building- related asthma in problem buildings where there are excess chest  complaints among occupants in comparison to buildings where there are  not complaints; or provide exposure-response studies of many building  environments and populations.
Improve sampling and exposure assessment methods for mold and its  components (for example, by conducting research that will lead to  standardization of protocols for sample collection, transport, and analysis  or developing or improving methods of personal airborne exposure  measurement, DNA-based technology, or assays for bioaerosols, etc.).
Develop standardized metrics and protocols to assess the nature, severity,  and extent of dampness and effectiveness of specific measures for  dampness reduction.
Overall, agency officials reported that 38 of the ongoing projects—or  nearly 60 percent—address asthma. In this respect, the federal mold  research portfolio for EPA, HHS, and HUD, ongoing as of October 1, 2007,  appears to be weighted toward addressing research gaps identified in the  Institute of Medicine’s 2000 report, Clearing the Air: Asthma and Indoor  Air Exposures. The research activities federal officials reported as  addressing one or more of the asthma-related research gaps include  studies using animals. For example, one focuses on gestational exposure  in mice to mold extracts and the effect this exposure has on the  development of allergy or asthma in adult life; one assesses in mice the  relative allergenic potency of molds statistically more common in water- damaged homes; and another is developing animal models (using mice and  rats) to evaluate the pulmonary inflammatory response to mold products  collected from indoor dust samples from buildings where people have  reported respiratory symptoms and from buildings with no reported health  complaints. Other asthma-related research activities are aimed, for  example, at better understanding the relationship between respiratory  symptoms and exposure to water-damaged homes in posthurricane New  Orleans and at evaluating the respiratory health of staff and students  attending schools that expose them to varying degrees of dampness.  (Summaries of the 65 research activities conducted or sponsored by EPA,  HHS, and HUD are provided in a supplement to this report—see GAO-08- 984SP.)
Many of the projects that address asthma also address sampling and  measurement methods. Research that provides high-quality, consistent  methodologies for sampling and measuring mold is essential to progress in  evaluating the health effects of exposure to mold. For example, the  Institute of Medicine reported in 2004 that evidence of an association  between exposure to mold and 15 specific health effects is inadequate or  insufficient to permit a conclusion regarding the presence of an  association because of the insufficient quality, consistency, or statistical  power of the available studies. This report, Damp Indoor Spaces and  Health, identified the need for standardized metrics and protocols. The  Institute’s earlier 2000 report that focused on asthma had previously  identified the need to improve exposure assessment methods for mold.
Overall, EPA, HHS, and HUD reported 36 research activities that address  sampling and exposure assessment methods or standardized metrics and  protocols. While a number of the research activities address these  measurement methods as part of investigations focusing on specific health  effects or other issues related to indoor mold, several focus solely or  primarily on developing measurement methods. For example, HHS’s  NIOSH is working to develop biomarkers of mold exposure to lead to  objective, standardized measures of exposure to support reproducible and  comparable analyses in health studies, including large-scale  epidemiological studies. HHS’s National Institute of Environmental  Health Sciences has three separate studies: (1) evaluating available  biomarkers of exposure and effect for specific molds that may cause  systemic toxicity, (2) developing tests for allergenic mold species and  toxin-producing molds found in water-damaged homes that can be used to  objectively assess mold exposure in buildings, and (3) testing the  feasibility of a flexible and low-cost measurement method for allergens,  including mold. Another example of ongoing research focusing on mold  identification is HHS’s CDC work to develop and validate DNA-based  methods for identification and fingerprinting medically important molds  because “the absence of a robust species/strain identification scheme has  hampered the rapid identification of novel species and the associated  burden of disease.”
EPA and HUD also reported working on DNA-based assessment methods.  Specifically, agency officials reported ongoing work using, in part, a DNA- based method for analyzing 36 species of mold that EPA developed,  patented, and has licensed commercial laboratories to perform. Working  with HUD, EPA used this method to develop a standard sampling and  analytic process that then led to the development of the Environmental  Relative Moldiness Index (ERMI) scale for U.S. homes. According to EPA,  this index provides a simple, objective evaluation of the mold burden in a  home. EPA reported ongoing epidemiological studies using the ERMI scale  aimed at determining if the ERMI values can be used to understand the  risk of asthma or related respiratory symptoms.
While most of the 65 ongoing research activities involving indoor mold are  addressing asthma and critical data gaps in sampling and measurement  methods identified in the 2000 and 2004 Institute of Medicine reports,  some other important data gaps identified in the 2004 report are being  studied to a lesser degree than the gaps identified in the 2000 report.  Notably, of the 15 data gaps identified in these reports, agency officials  reported that only 9 research activities address to some extent 3 of the  gaps identified in the 2004 report that follow.
Research the relationship between mold and dampness and acute  pulmonary hemorrhage or hemosiderosis in infants.
Determine the effects of human exposure to Stachybotrys chartarum in  indoor environments.
Determine, for mycotoxins, the dose required to cause adverse health  effects in humans via inhalation and skin (dermal) exposure; techniques  for detecting and quantifying mycotoxins in tissues; or the effects of long- term (chronic) exposures to mycotoxins via inhalation.
Officials from EPA, HHS, and HUD reported only one research activity  examining the relationship between mold and dampness and acute  pulmonary hemorrhage or hemosiderosis in infants—a rare but serious  health condition whose relation to exposure to indoor mold remains  unsettled, as discussed earlier. This research is aimed at developing  quantitative biomarkers for the toxin-producing mold species  Stachybotrys chartarum—a mold that has been implicated in cases of  acute pulmonary hemorrhage in infants—to facilitate epidemiological and  other studies examining mold-related health effects. Sponsored by HHS’s  National Institute of Environmental Health Sciences, this research will  support but does not directly address the 2004 Institute of Medicine’s  recommendation for research on the relationship between mold and  dampness and acute pulmonary hemorrhage in infants. Specifically, the  Institute of Medicine report concluded that the role of Stachybotrys  chartarum in cases of acute idiopathic pulmonary hemorrhage in infants  that had been studied remained controversial and encouraged HHS’s CDC  to pursue surveillance and additional research on the issue to resolve  outstanding questions because this condition has serious health  consequences. The Institute of Medicine further stated that epidemiologic  and case studies should take a broad-based approach to gather and  evaluate information on exposures and other factors that would help  identify the causes of acute idiopathic pulmonary hemorrhage in infants,  including dampness and agents associated with damp indoor  environments and environmental tobacco smoke, among others.  According to CDC officials, the agency is not currently conducting either  epidemiological or case studies on acute pulmonary hemorrhage in  infants.
Five research activities that federal agencies reported were addressing the  toxin-producing mold species Stachybotrys chartarum were: part of two  studies on asthma; a study to develop tests for allergenic mold species and  toxin-producing molds found in water-damaged homes and a study to  develop quantitative biomarkers to assist epidemiological and other  research examining mold-related health effects (both discussed above as  also addressing other data gaps); and a follow-up study analyzing archived  serum and house dust samples for Stachybotrys chartarum and related  mycotoxins in the context of the clinical symptom profiles previously  gathered on the study participants.
The research gap on the health effects of exposure to mycotoxins—toxins  that can be produced by certain types of mold and may potentially cause  adverse health effects—is being addressed to some extent by four  research activities, according to agency officials. One of the activities will  assess the potential for molds found in damp or water-damaged buildings  to cause nervous system or systemic toxicity. A second activity aims to  develop improved sensors for detecting mycotoxins in contaminated food  and feed to support proper remedial actions. A third activity is using an  animal model to understand the disease pathogenesis of hypersensitivity  pneumonitis—a relatively rare but potentially serious allergic reaction in  susceptible persons that can, in its chronic form, result in permanent lung  damage. Lastly, a fourth activity is a study of the mechanistic indicators  of childhood asthma that uses air, biologic and clinical measures as well as  molecular biology, chemistry, and gene technologies to identify factors  that affect individual susceptibility to asthmatic responses. EPA reported  that while this study is not directed at mold per se, the secondary data  being collected could address some other research activities that the  Institute of Medicine reports identified as relating to sampling and  exposure assessment and mycotoxins, among others.
Finally, EPA and HHS reported they had completed 42 mold-related  research activities between January 1, 2005, and September 30, 2007. In  general, these activities address topics such as asthma and sampling and  measurement methods, reflected in the portfolio of agencies’ ongoing  research activities. Information on the recently completed research  activities is provided in a supplement to this report (see GAO-08-984SP).
section_title: Limited Planning and Coordination of Research Activities May Affect Their Ability to Close Data Gaps on the Health Effects of Exposure to Indoor Mold
paragraphs: While the information on research activities relating to the health effects  of exposure to indoor mold provides some insight into the extent to which  federal agencies are addressing scientific data gaps identified by the  Institute of Medicine in 2000 and 2004, the extent to which these ongoing  research activities will effectively advance scientific knowledge in these  areas is not clear. Specifically, the research is not guided by an  overarching strategic plan or entity that would help agencies work  together to identify their research priorities on the health effects of mold.  Instead, agencies generally determine independently which research  activities they will support using a variety of criteria. This lack of clearly  articulated, common research goals is exacerbated by the limited intra-  and inter-agency planning and coordination of research activities among  federal agencies. Specific information that highlights planning and  coordination limitations follows.
Selection criteria for research the agencies sponsor are not always  linked to identified data gaps. Several EPA, HHS, and HUD officials  indicated that selection of priorities for research can be based on various  considerations, including agency expertise in a particular area or input  from external stakeholders. For example, both HHS and HUD officials  noted that ideas for research priorities can come from former grantees.
A key planning document that several EPA officials reported  consulting is now outdated. Specifically, the agency’s 2005 Program  Needs for Indoor Environments Research document, which outlines the  agency’s research needs for the indoor environment and mold, among  other topics, reflects input from the Institute of Medicine’s 2000 report but  not the more recent 2004 report, which also identified a number of  important data gaps. EPA officials told us that the agency’s research  related to asthma and mold’s health effects has been a priority, in part,  because this topic was identified in the 2000 Institute of Medicine report,  Clearing the Air: Asthma and Indoor Air Exposures.
Some officials stated that the 2004 Institute of Medicine report on  indoor mold has not influenced their research priorities on this  topic. While officials at HHS’s NIOSH reported that the Institute of  Medicine’s 2004 report had a “major impact” on what indoor  environmental quality research their institute conducts, HHS officials from  two of the National Institutes of Health noted that this report did not affect  their institutes’ internal priorities in this area. One official stated that while  the publication of this report did not change any of their internal priorities,  it may have encouraged external interest in mold research.
The process that NIH uses to fund outside research may also limit  the extent to which identified data gaps are addressed. Specifically,  federal officials from three different NIH institutes that sponsored 29 of  the 65 ongoing research activities as of October 1, 2007, reported that 19  were unsolicited—that is, they were initiated by investigators outside the  institutes. Most NIH-funded research is initiated by such investigators.  These investigators submitted research proposals that were of interest to  them and thus were not necessarily responsive to specific agency  priorities. Along these lines, officials at one institute said they generally  fund indoor mold research only because of outside investigators’ interest.  Unsolicited proposals are ranked for funding through a rigorous peer- review process for, among other things, scientific merit and the  significance of the research. While the specific topic of the research is  considered in light of its potential impact on public health during peer  review, NIH officials said that specific gaps identified in the Institute of  Medicine’s report may well have a lower significance relative to the three  institutes’ many other scientific priorities. That is, while the three  institutes do solicit research on areas considered to be priorities, studies  on the health effects of exposure to indoor mold have generally not been  in this category.
Less than half of the agencies’ 65 ongoing research activities are  being coordinated, either within or outside their agencies.  Specifically, in responding to our survey of ongoing research activities  involving the health effects of indoor mold, EPA, HHS, and HUD reported  that 28 of their 65 research activities are being coordinated (see fig. 1). In  other work, we identified practices that agencies should use when  coordinating their activities, including (1) defining and articulating a  common outcome, (2) identifying and addressing needs by leveraging each  others’ resources, and (3) agreeing on agency roles and responsibilities.  Especially when agencies are conducting research activities addressing  the same data gap, coordination is important to ensure inappropriate  duplication of efforts does not occur and to best leverage limited federal  resources. Even in these cases, however, a significant number of activities  are not being coordinated. For example, of the 32 EPA, HHS, and HUD  research activities seeking to identify which environmental factors, such  as mold, contribute to the development or exacerbation of asthma, federal  officials reported that 18 activities are not being coordinated. Similarly,  agencies are not coordinating on 22 of 36 research activities related to  sampling and measurement methods.
Further, the coordination activities reported by federal officials vary  widely. In some cases, the federal officials we surveyed reported internal  and external coordination on a specific research activity. For example, an  EPA official noted that his unit conducted one of its research activities in  conjunction with another unit within the agency, provided updates  regarding the activity to another unit, and collaborated with another  federal agency to write papers based on this research. Coordination was  more limited in other cases. Specifically, in many cases, research activities  were only coordinated within the agency—and often, with only one other  unit within the agency. For example, one NIOSH official reported that, for  one activity, his unit coordinated with another unit within NIOSH by  supplying certain instruments.
Importantly, while agencies sometimes coordinate on individual research  activities, we did not identify any sustained efforts to coordinate agencies’  indoor mold research priorities. In the few instances in which officials  reported that they coordinated with others on research priorities, it  appeared that these partnerships did not specifically address mold-related  priorities. For example, while EPA officials told us that they recently met  with officials from HHS’s CDC to discuss mutual research opportunities  related to the indoor environment, these meetings did not address mold  research priorities.
Federal agencies are not using the existing Federal Interagency  Committee on Indoor Air Quality as a forum to coordinate their  research activities on indoor mold. As discussed earlier, EPA serves as  the executive secretary of the Federal Interagency Committee on Indoor  Air Quality. We found that the committee addresses federal research  activities on indoor air quality on an informal basis. For example, our  analysis of the minutes of the 11 committee meetings from February 2005  to February 2008 shows that agency priorities related to indoor air quality  research, which could include research on mold, were discussed only a  few times. In one case, EPA officials described how their agency had  developed its research needs on indoor environments, which it published  in a document later in 2005 titled Program Needs for Indoor  Environments Research. In this case, EPA was not seeking input from  other agencies on research needs and priorities but rather was informing  other agencies of decisions EPA had made. Moreover, EPA, HHS, and  HUD officials who participate in committee meetings told us that they had  not discussed or sought input on their agency’s mold-related research  priorities during committee meetings. Further, according to committee  meeting minutes, the information agency officials share at committee  meetings regarding their mold research is limited to describing selected  ongoing activities and issues related to their funding. When mold-related  research was discussed during the 3-year period we reviewed, it was  usually to provide an update on the status of some individual research  projects. In several instances, officials also used the meetings to advertise  the availability of funding for research on indoor air quality issues, which  could include research on mold, or to announce the funding of mold- related research.
Currently, the committee holds 2-1/2 hour meetings in person and by  conference call three times a year that interested parties outside the  federal government can access. The agendas for the meetings are based on  input to EPA from member and nonmember agencies who propose topics  they would like to discuss. According to officials from one of the  participating agencies, the Consumer Product Safety Commission, the  Federal Interagency Committee on Indoor Air Quality had more  substantive discussions in the past on research projects, funding, and  which research priorities needed to be addressed than it does now.
The role of the Federal Interagency Committee on Indoor Air Quality has  changed over time. Established in response to congressional committee  direction in 1983, the committee, according to an EPA report, was to (1)  coordinate federal indoor air quality research; (2) provide for liaison and  the exchange of information on indoor air quality research among federal  agencies, and with state and local governments, the private sector, the  general public, and the research community; and (3) develop federal  responses to indoor air quality issues. According to a 1988 report on the  structure and operation of the committee, the committee comprised 16  member agencies and was co-chaired by EPA, the Consumer Product  Safety Commission, DOE, and HHS. This report noted that considerable  agreement existed among member agencies that the primary role of the  committee was to coordinate federal indoor air activities. Further,  coordination activities were specified to include joint project planning and  implementation; contributions to and review of member agency indoor  plans, reports, and publications; communication on technical and  nontechnical issues and activities; and advising on, and fostering  multiagency participation in, indoor air program and research activities of  individual agencies. The committee met quarterly and had standing work  groups covering indoor air quality research areas to address a diverse  range of indoor air quality research issues, such as radon, formaldehyde,  and allergens and pathogens (which include molds). The work groups,  which are no longer active, were to coordinate research activities in these  areas and identify future indoor air quality research. EPA used the  committee to coordinate air quality research and assist in implementing  the indoor air quality research and development program established by  Congress in 1986. For example, in 1989 and 1999, EPA used the committee  to help it develop two reports that identified the individual research  activities on indoor air quality that federal agencies were conducting. EPA  has taken the lead in directing committee activities in the past, such as  chairing meetings, and this role continues today.
section_title: Federal Guidance to the General Public Identifies Various Health Effects Associated with Exposure to Indoor Mold, as well as Strategies to Limit It, Some of Which Are Inconsistent
paragraphs: The Consumer Product Safety Commission, EPA, FEMA, HHS, and HUD  guidance documents we reviewed identify health effects associated with  indoor mold in a residential setting but sometimes omit less common but  serious health effects. Most of the guidance documents recommend  similar strategies for minimizing mold growth. While guidance documents  that discuss mold mitigation offer consistent advice about detecting mold,  some provide conflicting information about cleaning agents and the  appropriate level of protective equipment individuals need when  mitigating mold in their homes.
subsections: section_title: Federal Guidance Cites Various Adverse Health Effects of Exposure to Indoor Mold but in Some Cases Omits Less Common but Serious Effects
paragraphs: A majority of the 32 documents we reviewed that provide guidance to the  general public on the health effects of indoor mold in their homes—issued  by the Consumer Product Safety Commission, EPA, FEMA, HHS, and  HUD—identify asthma and upper respiratory tract symptoms as potential  health effects. In addition, many of these federal guidance documents cite  unspecified allergic symptoms and skin symptoms, such as dermatitis,  rashes, and hives. The six adverse health effects the Institute of Medicine  found to be associated with indoor mold in 2004 are included in the 32  guidance documents to varying extents. However, all six adverse health  effects are included in only two guidance documents, although a majority  of the guidance was issued after the publication of the 2004 Institute of  Medicine report.
Further, only a few of the 32 guidance documents discuss adverse health  effects associated with mold that are less common but serious. Such  health effects include opportunistic infections or fungal colonization in  immune-compromised individuals and hypersensitivity pneumonitis, a  relatively rare allergic reaction in susceptible persons characterized by  fever, chills, dry cough, and a flulike feeling that can, in its chronic form,  result in permanent lung damage. Because these less common but  potentially serious adverse health effects are infrequently cited in the  guidance documents, some individuals consulting these guidance  documents may not take appropriate precautions when they are exposed  to indoor mold. Table 1 identifies the potential adverse health effects cited  in 6 or more of the 32 guidance documents we reviewed. (App. V provides  a list of the guidance documents we reviewed and information on how to  access them.)
Moreover, most of the federal guidance documents we reviewed describe  populations that may be particularly sensitive to indoor mold. However,  few of the documents identify all of the populations that should take extra  precautions to limit exposure to indoor mold. According to an HHS  guidance document, these populations include the immune-compromised  as well as those with asthma, chronic lung diseases, and allergies to mold.  Immune-compromised individuals include organ transplant recipients, HIV  patients, individuals with leukemia or lymphoma, and those undergoing  cancer chemotherapy or other immunosuppressant drug therapies. HHS  also recommends “due caution” for children, pregnant women, and the  elderly who are exposed to indoor mold. Although some of the guidance  documents identify several of these populations, some list only one or two.  As a result, individuals consulting these guidance documents, especially  those who are particularly vulnerable to mold exposure, may not be fully  apprised of the risks associated with such exposure.
We recognize that the guidance documents we reviewed may address  health effects and particularly sensitive populations in varying levels of  detail because of differences in purpose and intended audience. For  example, several EPA guidance documents targeted toward particular  populations, such as teens, the elderly, and people with low literacy levels,  are limited in their scope and level of detail. In contrast, HHS’s document,  Mold Prevention Strategies and Possible Health Effects in the Aftermath  of Hurricanes and Major Floods, which is targeted to the general public  as well as to public health officials, includes a detailed discussion of  numerous potential health effects that may result from exposure to indoor  mold. Although not all guidance documents need to provide a  comprehensive list of all of the potential health effects of exposure to  indoor mold, the information provided should be sufficient to alert the  public about potential adverse health effects of exposure to indoor mold,  highlight specific populations that are particularly vulnerable to such  exposure, and not conflict among documents.
section_title: Guidance on Minimizing Indoor Mold Growth in Homes Is Generally Consistent
paragraphs: Most of the 32 guidance documents issued by the Consumer Product  Safety Commission, EPA, FEMA, HHS, and HUD that we reviewed  describe how to minimize indoor mold growth in the home. These  documents generally advise that residents reduce indoor moisture or  humidity levels, and their recommendations for doing so are generally  consistent. A majority of these guidance documents recommend that  residents keep areas dry and address moisture sources, such as leaks or  spills. Some of the guidance documents also recommend managing  specific sources of moisture or humidity by, for example, preventing water  from entering the house, ventilating and cleaning kitchens and baths to  reduce moisture buildup, and repairing and insulating pipes. In addition, a  majority of the documents recommend promptly drying wet items. Nearly  half of the documents that provide more specific recommendations note  that porous items, such as carpets, must be dried within 48 hours to avoid  the growth of mold and say that if more than 48 hours have elapsed, these  items should be discarded.
A number of the guidance documents that address strategies to minimize  indoor mold growth also advise residents to maintain indoor relative  humidity within specific ranges because high relative humidity can lead to  water condensation on indoor surfaces, such as walls and windows, which  can support mold growth. However, we note that the humidity ranges  specified by the guidance documents vary. For example, while all the  guidance documents that address relative humidity recommend  maintaining it at 60 percent or below, one FEMA document recommends  maintaining the relative humidity below 40 percent, and three guidance  documents issued by HHS recommend a relative humidity range between  40 percent and 60 percent. Such differences in guidance to the public  could cause some confusion about this aspect of minimizing indoor mold  growth.
section_title: Guidance on Mitigating Exposure to Indoor Mold Is Sometimes Inconsistent about Cleanup Agents and Protective Clothing and Equipment
paragraphs: A majority of the guidance documents we reviewed provide information to  the public about mitigating exposure to indoor mold. Many of the  documents agree that if mold can be either seen or smelled, it should be  removed. Recommendations on detecting mold are broadly consistent  with information in a 2001 EPA report on mold mitigation in schools and  commercial buildings, which is cited by a number of the guidance  documents as a resource for mitigation of residential mold growth.  Further, the eight guidance documents that discuss sampling or testing to  measure the quantity or type of mold in the indoor environment advise  against it in most circumstances because the results of such testing may  not be useful. For example, one of these documents explains that no  standardized method exists either to measure the magnitude of exposure  to mold or to relate a particular level of exposure to adverse health effects.  Another guidance document notes that it is generally not necessary to  determine the species of mold present. Finally, many of the guidance  documents that discuss mitigation note that if the mold is extensive (for  example, if it covers more than 25 square feet) or if it is found in the  heating or air conditioning systems, residents should consult further  guidance, such as EPA’s Mold Remediation in Schools and Commercial  Buildings, or hire a professional contractor.
While a majority of the guidance documents we reviewed discuss how to  remove mold once a problem has been identified, there is some  inconsistency about which cleaning agents to use. For example, two  guidance documents recommend using detergent to clean mold. On the  other hand, HHS’s Mold Prevention Strategies and Possible Health Effects  in the Aftermath of Hurricanes and Major Floods advises that bleach  may be warranted if the mold growth is due to floodwater, which can be  contaminated. Another guidance document, issued by EPA, also advises  that bleach be used when individuals who are particularly susceptible to  adverse health effects from mold, such as those who are immune- compromised, are exposed to indoor mold. In contrast, six of the guidance  documents we reviewed, including several of the HHS documents,  recommend the use of bleach irrespective of certain populations or  whether the mold growth is due to flooding. According to EPA’s 2001  report on mold mitigation, mold growing on hard (nonporous) surfaces  should be scrubbed with water and detergent and then vacuumed. This  report recommends using bleach only in limited circumstances—such as  when immune-compromised individuals are present—because bleach, a  biocide, is toxic to humans. These differences among guidance documents  could lead to confusion among the general public about the safest and  most effective way to remove mold. For example, if bleach is not  necessary in most instances, using it unnecessarily could lead to avoidable  problems, since bleach itself is a hazardous substance that can generate  toxic fumes if it is mixed with ammonia-based cleaners.
In addition, many of the guidance documents we reviewed discuss using  personal protective equipment while removing mold but, in some cases,  recommend different levels of protection for the general public as well as  for certain populations that may be more sensitive to mold exposure. For  example, as figure 2 shows, the guidance documents provide inconsistent  recommendations for the general public about wearing respiratory  protection, eye protection, and skin (dermal) protection (such as long- sleeved shirts and long pants) for cleanups of limited mold  contamination.
In addition, although 26 guidance documents caution that certain  populations may be more sensitive to mold, only 2 of them, issued by HHS  in 2005 and 2006, provide specific recommendations about the varying  levels of personal protection that such populations should use under  various circumstances. The HHS documents state that, when inspecting or  assessing damage, individuals with certain lung diseases should wear  respirators, while healthy individuals need no special protection for these  tasks. However, these documents warn that individuals with  “immunosuppression,” such as those undergoing cancer treatment or  those who have leukemia or lymphoma, should wear a respirator, gloves,  and safety goggles when inspecting or assessing damage. Further, those  with “profound immunosuppression”—such as those with HIV infection— should avoid all exposure to mold.
Guidance documents also provide inconsistent information about the  types of respiratory protection to use when cleaning up mold. Of the 15  guidance documents that recommend the use of respiratory protection  during cleanup, 6 list items such as dust masks, which do not protect  against mold because it can pass through them. Nine of the documents  suggest “N-95 respirators,” which filter 95 percent of airborne particles and  can protect against inhaling mold. Moreover, only 3 of the guidance  documents recommending the use of N-95 respirators discuss the need for  proper fit—which could impact their effectiveness, according to the HHS’s  NIOSH, the federal agency that approves these respirators. Furthermore,  only 1 guidance document, issued by HHS, warns that respirator use may  not be appropriate if an individual has a pre-existing medical condition  that makes it difficult to breathe while wearing a respirator.
A number of agency officials said they revisit the content of their guidance  documents following significant new scientific discoveries or in response  to events such as major flooding or hurricanes. We note that in the past  few years, important updated information on the health effects of  exposure to indoor mold and ways to protect against unnecessary  exposure has been provided in three documents: the Institute of  Medicine’s 2004 report and two HHS guidance documents on mold issued  in 2005 and 2006 in the aftermath of the hurricanes and major floods on  the Gulf Coast. Nevertheless, some of the guidance documents we  reviewed do not yet reflect important updated information that these  publications provide. Overall, despite the useful information provided in  the federal guidance we reviewed, some omissions and inconsistencies  could cause some individuals to be exposed to indoor mold unnecessarily.
section_title: Conclusions
paragraphs: While the current research activities on indoor mold conducted or  sponsored by EPA, HHS, and HUD address identified health-related  research gaps to varying degrees, these activities are largely  uncoordinated within and across agencies, and many are generated by  independent researchers rather than by agency solicitations for specific  research. This limited coordination contributes to the lack of standardized,  quantitative methods for measuring exposure to mold that has impeded  the advancement of knowledge about health effects and may result in  unnecessary duplication of research efforts. Without more systematic  coordination of planned and ongoing research activities, future research  may not be prioritized to best fill data gaps or be of sufficient quality and  consistency to more definitively support conclusions about any  associations to indoor mold and adverse health effects. Specifically, the  Institute of Medicine was unable to associate a number of adverse health  effects with exposure to mold because the available studies were of  “insufficient quality, consistency, or statistical power to permit a  conclusion regarding the presence of an association.”
An existing interagency committee—the Federal Interagency Committee  on Indoor Air Quality—could provide an effective vehicle for enhancing  the coordination of research activities. As the executive secretary and co- chair, EPA guides the activities of this committee, which was established  in response to congressional direction to, among other things, coordinate  federal indoor air quality research and foster information sharing among,  for example, federal agencies and the public. While the committee  provides a forum for informal information sharing, it has not been used in  recent years to support systematic coordination of federal research  priorities or agendas for indoor air research. Since the Federal Interagency  Committee on Indoor Air Quality was established in the 1980s, significant  advances in communications technologies, such as the Internet, have  transformed the exchange of information—for example, through Web  pages and hyperlinks to documents and Web sites. These communications  advances can facilitate the coordination among federal agencies, state and  local governments, the private sector, the research community, and the  general public that the Federal Interagency Committee on Indoor Air  Quality was established to accomplish.
Overall, the federal guidance documents we reviewed that provide  information to the general public about the health effects of exposure to  indoor mold, ways to minimize mold growth, and safe and effective  methods for cleaning up provide generally useful information. However,  some documents do not sufficiently advise the general public about some  potentially serious health effects, and others provide inconsistent  information about cleaning agents and appropriate protective gear.  Regarding protective gear, some documents do not provide information  about how populations that are particularly vulnerable to adverse health  effects should protect themselves. In fact, populations with certain  immunosuppression conditions should avoid exposure to mold but many  guidance documents do not state this. As a result, the public may not be  sufficiently aware of the health risks they or their family members may  face, and they may also be confused about how to approach cleaning up  mold in their homes.
section_title: Recommendations for Executive Action
paragraphs: We recommend that the Administrator, EPA, use the Federal Interagency  Committee on Indoor Air Quality to accomplish the following two actions.
Help articulate and guide research priorities on indoor mold across  relevant federal agencies, coordinate information sharing on ongoing and  planned research activities among agencies, and provide information to  the public on ongoing research activities to better ensure that federal  research on the health effects of exposure to indoor mold is effectively  addressing research needs and efficiently using scarce federal resources.
Help relevant agencies review their existing guidance to the public on  indoor mold—considering the audience and purpose of the guidance  documents—to better ensure that it sufficiently alerts the public,  especially vulnerable populations, about the potential adverse health  effects of exposure to indoor mold and educates them on how to minimize  exposure in homes. The reviews should take into account the best  available information and ensure that the guidance does not conflict  among agencies.
section_title: Agency Comments and Our Evaluation
paragraphs: We provided the Consumer Product Safety Commission, EPA, FEMA,  HHS, and HUD with a draft of this report and the related supplement  (GAO-08-984SP) for the agencies’ review and comment. In its response,  EPA generally agreed with our recommendations that it use the Federal  Interagency Committee on Indoor Air Quality to, among other things, help  articulate and guide research priorities on indoor mold across relevant  federal agencies and help relevant agencies review their existing guidance  to the public on indoor mold to better ensure that it sufficiently alerts the  public about the potential adverse health effects of exposure to indoor  mold and educates the public on how to minimize exposure in homes. In  commenting on the draft report, HUD and the Consumer Product Safety  Commission also generally supported our recommendations to EPA.  FEMA did not provide comments on the report, and HHS’s comments did  not address our recommendations to EPA. The Consumer Product Safety  Commission, EPA, HHS, and HUD also provided technical comments on  our report, and HHS provided a technical comment on the supplement;  their comments were incorporated, as appropriate.
As agreed with your office, unless you publicly announce the contents of  this report earlier, we plan no further distribution until 30 days from the  report date. At that time, we will send copies to the Acting Chairman,  Consumer Product Safety Commission; Administrator, EPA;  Administrator, FEMA; Secretary, HHS; Secretary, HUD; and other  interested parties. We will also make copies available to others upon  request. In addition, the report will be available at no charge on the GAO  Web site at http://www.gao.gov.
If you or your staff have any questions about this report, please contact me  at (202) 512-3841 or stephensonj@gao.gov. Contact points for our Offices  of Congressional Relations and Public Affairs may be found on the last  page of this report. GAO staff who made major contributions to this report  are listed in appendix VI.
section_title: Appendix I: Objectives, Scope, and Methodology
paragraphs: The objective of this review was to assess federal agencies’ activities to  minimize and mitigate the health effects of exposure to indoor mold.  Specifically, we examined (1) what recent reviews of the scientific  literature have concluded about the health effects of exposure to indoor  mold; (2) the extent to which federal research addresses data gaps related  to the health effects of exposure to indoor mold; and (3) what guidance  key federal agencies are providing to the public on the health risks of  exposure to mold, and on minimizing and mitigating that exposure, and  the extent to which the guidance is consistent. Our review focuses on the  health effects and guidance to the general public related to indoor mold in  homes and does not address occupational exposures or technical guidance  documents targeted to specialized audiences, such as medical  professionals and emergency response workers.
To determine what recent reviews of the scientific literature have  concluded about the health effects of exposure to indoor mold, we  primarily relied on the findings in the National Academies’ Institute of  Medicine comprehensive report issued in 2004, Damp Indoor Spaces and  Health. To identify more recent reviews of the health effects of exposure  to indoor mold, we conducted a literature search. We searched for reviews  and meta-analyses, rather than individual studies, published in English in  2005, 2006, and 2007, primarily using PubMed, a bibliographic database  service of the U.S. National Library of Medicine. We conducted 19  different searches of PubMed using combinations of the following search  terms: mold, exposure, health, indoor, glucan, microbial volatile organic  compounds, mycotoxins, ergosterol, hemolysins, fungal extracellular  polysaccharides, fungal/hyphal fragments, allergens, stachybotrys, acute  ideopathic pulmonary hemorrhage, acute pulmonary hemorrhage and  infants, and hemosiderosis. As part of these searches, we used PubMed’s  Clinical Queries option to find Systematic Reviews, which cover a broad  set of articles that build consensus on biomedical topics. We also  conducted a search for reviews and meta-analyses using the search  strategy “mold AND (exposure OR indoor OR health)” in 15 other  databases providing comprehensive worldwide coverage of scientific and  technical journals on relevant topics. We reviewed the abstracts of all  search results and obtained copies of the publications for which no  abstracts were available, unless the available information indicated that  the publication was unrelated to our review. We evaluated the relevance of  the abstracts and publications and identified those that addressed the  health effects of exposure to indoor mold and its constituents or products,  excluding those that addressed dietary exposures, exposures in industrial  or agricultural settings, publications focused on yeasts, case studies of  mold in particular locations, and any publications that were clearly not  meta-analyses or reviews of the scientific literature. Twenty of the reviews  met our criteria (see app. II for a list of these reviews). To assess the  credibility, reliability, and methodological soundness of these  publications, a senior GAO analyst with a doctorate in epidemiology  reviewed each of the publications and any additional methodological  information obtained from the authors and considered such factors as the  bibliographies of evidence cited, the journals in which the articles were  published, and the extent to which they are primary authors of other  relevant articles. We did not examine the references cited by these studies  as part of our analysis. Some of the reviews may be based on primary  sources (for example, epidemiologic studies), while others may also be  based on sources that are themselves reviews of the scientific literature  (for example, the 2004 Institute of Medicine report). We concluded that all  20 reviews were sufficiently reliable for the purposes of this report.
We also used the 2004 Institute of Medicine report to help identify areas  where additional research is needed to address scientific data gaps  primarily related to the health effects of exposure to indoor mold other  than asthma, as well as the institute’s 2000 report, Clearing the Air:  Asthma and Indoor Air Exposures, which focused on gaps related to  asthma. We conducted in-depth reviews of these reports, including their  methodology and conclusions, and we summarized the research needs  they identified related to the health effects of exposure to indoor mold.
To obtain information on federal research related to the health effects of  exposure to indoor mold, we conducted two surveys of officials at the  Environmental Protection Agency (EPA), the Department of Health and  Human Services (HHS), and the Department of Housing and Urban  Development (HUD) from November 2007 to May 2008. We used one  survey to (1) identify research activities related to the health effects of  indoor mold ongoing as of October 1, 2007, and (2) determine the extent to  which these research activities address the 15 data gaps identified in the  2000 and 2004 Institute of Medicine reports related to the health effects of  exposure to indoor mold. Respondents completed a survey for each  individual research activity ongoing as of October 1, 2007. We also used  this survey to identify the extent to which these activities were  coordinated both within and across agencies. We conducted a second  survey of these agencies to collect basic information on their mold-related  research activities completed from January 1, 2005, to September 30, 2007.  Overall, we received information on 107 research activities from 37 EPA,  HHS, and HUD officials. We received responses to our surveys from all  relevant officials and agency entities. Summaries of the research activities  conducted or sponsored by EPA, HHS, and HUD are provided in a  supplement to this report (see GAO-08-984SP).
We surveyed officials at EPA, HHS, and HUD because of these agencies’  past and current participation in mold research. Specifically, we identified  these agencies based on federal reports to Congress summarizing efforts  to improve indoor air quality and interviews with federal officials involved  in this research, among other things. We took a number of steps to ensure  that our surveys would obtain reliable information from the appropriate  agencies and officials regarding federal research activities on the health  effects of exposure to indoor mold. For example, to ensure that we sent  surveys to all agency officials involved in indoor mold-related research  activities, we provided audit liaisons and agency respondents with a list of  the units and officials in their agencies that we had identified as being  relevant. We also asked audit liaisons to verify that we had not omitted any  relevant units within their agencies and confirm whether other agency  officials identified during our interviews as potentially involved in indoor  mold-related research activities were involved with relevant activities.  When an audit liaison identified a new agency respondent involved in  indoor mold-related research activities, the individual was provided with  copies of our surveys. (See app. IV for information on the units we  contacted at these agencies.) We pretested our survey questions by  sending them to two researchers from EPA and the National Institutes of  Health (NIH) and incorporating their feedback into the final surveys. To  increase the response rate, we followed up with agency officials to obtain  responses from all relevant parties. We also performed a series of  reliability tests on the data we received, including (1) examining agency  submissions to exclude any that were either duplicates or did not meet our  criteria and (2) checking for missing data or discrepancies. When we  identified discrepancies or inconsistencies in the data, we followed up  with relevant agency officials. In addition, we interviewed EPA, HHS, and  HUD officials to determine the extent to which they coordinate their  research projects and their priorities for mold-related research. To assess  the extent to which the Federal Interagency Committee on Indoor Air  Quality has been used to coordinate federal research activities related to  the health effects of exposure to indoor mold, we reviewed relevant  reports and the minutes of committee meetings dating from February 2005  to February 2008, and we interviewed EPA and other officials involved  with the committee.
To determine what guidance key federal agencies are providing to the  general public on the health risks of exposure to indoor mold, and on  minimizing mold growth and mitigating exposure to mold in their homes,  and the extent to which the guidance is consistent, we focused our review  on the five federal agencies that provide information to the general public  on health risks and minimizing and mitigating exposure to contaminants,  including mold. The guidance we reviewed includes fact sheets,  brochures, booklets, and Web pages. Specifically, we reviewed guidance  on the health effects of mold in a residential setting issued by the  Consumer Product Safety Commission, EPA, HUD, HHS, and the Federal  Emergency Management Agency (FEMA) that was identified primarily  through online searches of federal Web sites and interviews with relevant  program officials. We selected guidance to the general public that  addresses health effects associated with indoor mold using a  nonprobability sample. We did not include technical documents targeted  to specialized audiences, such as medical professionals or emergency  response workers. Of the 78 guidance documents that met our initial  criteria, we selected 32 for detailed review on the basis of their content,  purpose, and the extent to which they specifically addressed indoor mold.  (In some cases, the documents broadly address indoor air contaminants  but only briefly mention mold.) Specifically, of the 34 mold-related  guidance documents FEMA issued to the general public responding to  specific disasters since 2004, we selected 8 for our review; we excluded  the other 26 because they contain essentially similar information. Further,  we included in our review the 8 guidance documents issued by the  Consumer Product Safety Commission and HUD that address health  effects associated with indoor mold; however, we excluded some guidance  documents issued by EPA and HHS primarily because they were similar to,  and thus duplicative of, other documents already included in our review.  We provided agency officials with an opportunity to review our list of  guidance documents and suggest additional documents for inclusion in  our review. We added relevant documents, as suggested. (See app. V for  the guidance documents included in our review.) Additionally, we  interviewed officials from the five agencies issuing the guidance to  determine their procedures for developing and issuing guidance  documents. The guidance documents we analyzed are publicly available  and can be accessed through the agencies’ Web sites.
We conducted this performance audit from January 2007 to September  2008 in accordance with generally accepted government auditing  standards. Those standards require that we plan and perform the audit to  obtain sufficient, appropriate evidence to provide a reasonable basis for  our findings and conclusions based on our audit objectives. We believe  that the evidence obtained provides a reasonable basis for our findings  and conclusions based on our audit objectives.
section_title: Appendix II: Recent Reviews of the Health Effects of Mold
paragraphs: The following list of recent reviews of the health effects of mold includes  two Institute of Medicine reports and 20 other reviews.
Borchers A.T., Chang C., Keen C.L., and M.E. Gershwin. “Airborne  Environmental Injuries and Human Health.” Clinical Reviews in Allergy  and Immunology, vol. 31, no. 1 (2006): 1-102.
Bush R.K., Portnoy J.M., Saxon A., Terr A.I., and R.A. Wood. “The medical  effects of mold exposure.” The Journal of Allergy and Clinical  Immunology, vol. 117, no. 2 (2006): 326-33.
Douwes J. “(1—>3)-Beta-D-glucans and respiratory health: a review of the  scientific evidence.” Indoor Air, vol. 15, no. 3 (2005): 160-9.
Etzel R.A. “Indoor and outdoor air pollution: Tobacco smoke, moulds and  diseases in infants and children.” International Journal of Hygiene and  Environmental Health, vol. 210, no. 5 (2007): 611-6.
Fisk, W.J., Lei-Gomez Q., and M.J. Mendell. “Meta-analyses of the  associations of respiratory health effects with dampness and mold in  homes.” Indoor Air, vol. 17, no. 4 (2007): 284-96.
Gray, M. “Molds and Mycotoxins: Beyond Allergies and Asthma.”  Alternative Therapies in Health and Medicine, vol. 13, no. 2 (2007): S146- 52.
Green B.J., Tovey E.R., Sercombe J.K., Blachere F.M., Beezhold D.H., and  D. Schmechel. “Airborne fungal fragments and allergenicity.” Medical  Mycology, vol. 44, no. S1 (2006): S245-55.
Habiba A. “Acute idiopathic pulmonary haemorrhage in infancy: Case  report and review of the literature.” Journal of Paediatrics and Child  Health, vol. 41, no. 9-10 (2005): 532-3.
Hope, A.P., and R.A. Simon. “Excess dampness and mold growth in homes:  An evidence-based review of the aeroirritant effect and its potential  causes.” Allergy and Asthma Proceedings, vol. 28, no. 3 (2007): 262-70.
Institute of Medicine, Clearing the Air: Asthma and Indoor Air  Exposures. Washington, D.C.: National Academy Press, 2000.
Institute of Medicine, Damp Indoor Spaces and Health. Washington, D.C.:  The National Academies Press, 2004.
Jarvis B.B., and J.D. Miller. “Mycotoxins as harmful indoor air  contaminants.” Applied Microbiology and Biotechnology, vol. 66, no. 4  (2005): 367-72.
Khalili B., Montanaro M.T., and E.J. Bardana Jr. “Inhalational mold  toxicity: fact or fiction? a clinical review of 50 cases.” Annals of Allergy,  Asthma & Immunology, vol. 95, no. 3 (2005): 239-46.
Lai K.-M. “Hazard Identification, Dose-Response and Environmental  Characteristics of Stachybotryotoxins and Other Health-Related Products  from Stachybotrys.” Environmental Technology, vol. 27, no. 3 (2006): 329- 35.
Laumbach R.J., and H.M. Kipen. “Bioaerosols and sick building syndrome:  particles, inflammation, and allergy.” Current Opinion in Allergy and  Clinical Immunology, vol. 5, no. 2 (2005): 135-9.
Mazur L.J., and J. Kim; Committee on Environmental Health, American  Academy of Pediatrics. “Spectrum of Noninfectious Health Effects From  Molds.” Pediatrics, vol. 118, no. 6 (2006): e1909-26.
Nuesslein T.G., Teig N., and C.H. Rieger. “Pulmonary haemosiderosis in  infants and children.” Paediatric Respiratory Reviews, vol. 7, no. 1 (2006):  45-8.
Phipatanakul W. “Environmental Factors and Childhood Asthma.”  Pediatric Annals, vol. 35, no. 9 (2006): 646-56.
Seltzer J.M., and M.J. Fedoruk. “Health Effects of Mold in Children.”  Pediatric Clinics of North America, vol. 54, no. 2 (2007): 309-33, viii-ix.
Susarla S.C., and L.L. Fan. “Diffuse alveolar hemorrhage syndromes in  children.” Current Opinion in Pediatrics, vol. 19, no. 3 (2007): 314-20.
Portnoy J.M., Kwak K., Dowling P., VanOsdol T., and C. Barnes. “Health  effects of indoor fungi.” Annals of Allergy, Asthma & Immunology, vol.  94, no. 3 (2005): 313-20.
Richardson G., Eick S., and R. Jones. “How is the indoor environment  related to asthma?: literature review.” Journal of Advanced Nursing, vol.  52, no. 3 (2005): 328-39.
section_title: Appendix III: EPA, HHS, and HUD Ongoing Research Activities Addressing Data Gaps Identified by the Institute of Medicine
paragraphs: Identify environmental factor that either lead to the development of athma or pre- cipitate ymptom in ubject who already have athma uin ood meaure of  funal expoure.
Improve amplin and expoure assssment method for mold and it component  (uch a reearch that will help lead to tandardization of protocol for ample col- lection, tranport, and analy; or develop or improve method of peronal airborne  expoure meaurement, DNA-baed technoloy, or assay for bioaerool, etc.)
Determine the association of dampness problem with athma development and  ymptom by reearchin the cauative aent (e.., mold, dut mite alleren)  and documentin the relationhip between dampness and alleren expoure.
Identify funal alleren or pattern of cross-reactivity amon funal alleren.
Collect and analyze data on the interaction amon multiple indoor aent (uch a  mold, peticide, and volatile oranic compound) and environmental factor (uch  a humidity, temperature, and ventilation).
Develop information on the possible advere health effect of dampness-related  emission of mold pore from buildin material and furnihings.
Determine how to meaure the effectiveness and health effect of mold remediation  effort.
Better characterize the possible influence of the duration of moiture damae on  health.
Develop tandardized metric and protocol to assss the nature, everity, and ex- tent of dampness and effectiveness of pecific meaure for dampness reduction.
Advance the undertandin of pecific bioaerool in relation to athma by tudyin the  epidemioloy of buildin-related athma in problem buildings where there are excess chet complaint amon occupant in comparion to buildings where there are not complaint;  or provide expoure-repontudie of many buildin environment and population.
Assss the effect of houin intervention (uch a prevention or remediation of  moiture problem, etc.) on dampness and advere health effect, includin the extent  to which intervention are associated with a decreae in the occurrence of advere  health effect, and identify effective and efficient intervention trateie.
Better characterize the effectiveness of variou mean of protection ued durin  mold remediation activitie.
Determine the effect of human expoure to Stachybotrys chartarum in indoor  environment.
Determine, for mycotoxin, the doe required to caue advere health effect in  human via inhalation and dermal expoure; technique for detectin and quantify- in mycotoxin in tissue; or the effect of lon-term (chronic) expoure to  mycotoxin via inhalation.
Reearch the relationhip between mold and dampness and acute pulmonary  hemorrhae or hemoidero in infant.
In fact, many of the activities are reported to address three or more gaps. Summaries of the 65  research activities conducted or sponsored by EPA, HHS, and HUD are provided in a supplement to  this report (GAO-0-94SP).
Agency officials reported that eight federal mold research activities currently being conducted do not  directly address any of the data gaps identified by the 2000 and 2004 Institute of Medicine reports.  Some of these studies were directed at medical treatments and others were focused on other  potential causes of asthma. For example, one study is evaluating whether chronic rhinosinusitis is  induced by an abnormal immune response to mold and therefore whether an anti-fungal agent will be  an effective treatment of the disease. Another study is developing and validating DNA-based methods  for identification and fingerprinting medically important fungi. Several of these research activities  focused on asthma. For example, two studies, one of children in El Paso and another of children in  Detroit, are primarily focused on the role of residential proximity to roadways in the development of  childhood asthma but also collected data on indoor exposures, including home dampness and the  presence of visible molds. Another study being conducted is designed to test the hypothesis that  asthma control in low income, urban adolescents and young adults can be improved with the addition  of exhaled nitric oxide as a marker for treatment guidance to conventional asthma management  guidelines; a secondary purpose of this study is to examine the role of allergy to molds in influencing  the effectiveness of the asthma management plan.
Asthma data gaps identified by the 2000 and 2004 Institute of Medicine reports.
Measurement methods data gaps identified by the 2000 and 2004 Institute of Medicine reports.
section_title: Appendix IV: Federal Agency Program Offices Contacted Regarding Their Mold- Related Research
paragraphs: We obtained information on federal research related to the health effects  of exposure to indoor mold from three key agencies—EPA, HHS, and  HUD. We obtained and analyzed information and interviewed program  managers and other officials responsible for research at these agencies.  Following are the offices, centers, and other program units we surveyed  regarding their mold-related research.
subsections: section_title: Environmental Protection Agency
section_title: Department of Health and Human Services
subsections: section_title: Centers for Disease Control and Prevention
section_title: National Institutes of Health
section_title: Office of the Assistant Secretary for Health
section_title: Office of the Assistant Secretary for Administration and Management
section_title: Department of Housing and Urban Development
section_title: Appendix V: Selected Publicly Available Federal Guidance Related to Mold
paragraphs: Consumer Product Safety Commission and the American Lung  Association, Biological Pollutants in Your Home (Bethesda, Md., 1990).  http://www.cpsc.gov/cpscpub/pubs/425.html (accessed May 8, 2008).
Consumer Product Safety Commission and the Environmental Protection  Agency, The Inside Story: A Guide to Indoor Air Quality (Washington,  D.C., 1995). http://www.epa.gov/iaq/pubs/insidest.html (accessed May 8,  2008).
Environmental Protection Agency, Addressing Indoor Environmental  Concerns During Remodeling (Washington, D.C., 2007).  http://www.epa.gov/iaq/homes/hip-concerns.html (accessed May 9, 2008).
Environmental Protection Agency, Age Healthier Breathe Easier  (Washington, D.C., 2004).  http://www.epa.gov/aging/resources/factsheets/ahbe_english_2004_0330.p df (accessed May 9, 2008).
Environmental Protection Agency, A Brief Guide to Mold, Moisture, and  Your Home (Washington, D.C., 2002).  http://www.epa.gov/mold/moldguide.html (accessed May 9, 2008).
Environmental Protection Agency, Cleaning Up After a Flood: Addressing  Mold Problems (Washington, D.C., 2005).  http://www.epa.gov/katrina/outreach/mold.pdf (accessed May 9, 2008).
Environmental Protection Agency, Controlling Moisture (Washington,  D.C., 2007). http://www.epa.gov/iaq/homes/hip-moisture.html (accessed  May 9, 2008).
Environmental Protection Agency, Live, Learn, Play—Tune in to Your  Health and Environment (Washington, D.C., 2004).  http://yosemite.epa.gov/ochp/ochpweb.nsf/content/dirt.htm (accessed May  9, 2008).
Environmental Protection Agency, Flood Cleanup—Avoiding Indoor Air  Quality Problems (Fact Sheet) (Washington, D.C., 2003).  http://www.epa.gov/mold/pdfs/floods.pdf (accessed May 9, 2008).
Environmental Protection Agency, Flood Cleanup and the Air in your  Home (Washington, D.C., 2006).  http://www.epa.gov/mold/flood/index.html (accessed May 9, 2008).
Environmental Protection Agency, What are ten things I need to know  about mold? (Washington, D.C., 2008). http://iaq.custhelp.com/cgi- bin/iaq.cfg/php/enduser/std_alp.php (accessed May 9, 2008).
Environmental Protection Agency, What You Can Do to Protect Children  from Environmental Risks (Washington, D.C., 2002).  http://yosemite.epa.gov/ochp/ochpweb.nsf/content/tips.htm (accessed May  9, 2008).
Environmental Protection Agency; Department of Agriculture,  Cooperative State Research, Education, and Extension Service;  Department of Housing and Urban Development; Montana State University  Extension Service; and Alabama Cooperative Extension System at Auburn  University, Healthy Indoor Air for America’s Homes (Bozeman, Mont.,  2007). http://www.montana.edu/wwwcxair/ (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Molds in the Environment (Atlanta, 2005).  http://www.cdc.gov/mold/faqs.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Facts About Mold And Dampness (Atlanta, 2005).  http://www.cdc.gov/mold/dampness_facts.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Mold Questions and Answers: Questions and Answers  on Stachybotrys chartarum and other molds (Atlanta, 2004).  http://www.cdc.gov/mold/stachy.htm (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Protect Yourself from Mold (Atlanta, 2006).  http://www.bt.cdc.gov/disasters/mold/protect.asp (accessed May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Mold Prevention Strategies and Possible Health Effects  in the Aftermath of Hurricanes and Major Floods (Atlanta, 2006).  http://www.cdc.gov/mmwr/preview/mmwrhtml/rr5508a1.htm (accessed  May 9, 2008).
Department of Health and Human Services, Centers for Disease Control  and Prevention, Population-Specific Recommendations for Protection  From Exposure to Mold in Buildings Flooded After Hurricanes Katrina  and Rita, by Specific Activity and Risk Factor (Atlanta, 2005).  http://www.bt.cdc.gov/disasters/mold/report/pdf/2005_moldtable5.pdf  (accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management  Agency, Dealing with Mold and Mildew in Your Flood Damaged Home  (Washington, D.C., 2005).  http://www.fema.gov/pdf/rebuild/recover/fema_mold_brochure_english.pd f (accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management  Agency, Got Mold? Clean, Disinfect and Dry (Wichita, Kans., 2007).  http://www.fema.gov/news/newsrelease.fema?id=37791 (accessed May 9,  2008).
Department of Homeland Security, Federal Emergency Management  Agency, Mold Can Be A Danger When Evacuees Return Home (Baton  Rouge, La., 2005). http://www.fema.gov/news/newsrelease.fema?id=19302  (accessed May 9, 2008).
Department of Homeland Security, Federal Emergency Management  Agency, Mold—A Growing Threat (Andover, Mass., 2006).  http://www.fema.gov/news/newsrelease.fema?id=26898 (accessed May 9,  2008).
Department of Homeland Security, Federal Emergency Management  Agency, Mold: A Health Hazard (Montgomery, Ala., 2005).  http://www.fema.gov/news/newsrelease.fema?id=20379 (accessed May 9,  2008).
Department of Homeland Security, Federal Emergency Management  Agency, Mold: Potential Threat to Health and Homes (Austin, Tex., 2005).  http://www.fema.gov/news/newsrelease.fema?id=19767 (accessed May 9,  2008).
Department of Homeland Security, Federal Emergency Management  Agency, Prompt Cleanup Of Mold And Mildew Is Essential (Newington,  N.H., 2006). http://www.fema.gov/news/newsrelease.fema?id=27186  (accessed July 1, 2008).
Department of Homeland Security, Federal Emergency Management  Agency, Water-Damaged Homes May Harbor Mold Problem (Washington,  D.C., 2007). http://www.fema.gov/news/newsrelease.fema?id=36536  (accessed May 9, 2008).
Department of Housing and Urban Development, About Mold and  Moisture (Washington, D.C., 2007).  http://www.hud.gov/offices/lead/healthyhomes/mold.cfm (accessed May 9,  2008).
Department of Housing and Urban Development, Healthy Homes Program  (Washington, D.C., 2003).  http://www.hud.gov/offices/lead/library/hhi/HH_Brochure_Revised.pdf  (accessed May 9, 2008).
Department of Housing and Urban Development, Mold and Moisture  Prevention: A Guide for Residents in Indian Country (Washington, D.C.,  2004).  http://www.hud.gov/offices/pih/ih/codetalk/docs/moldprevention.pdf  (accessed May 9, 2008).
Department of Housing and Urban Development, Mold (Washington, D.C.,  2005). http://www.hud.gov/offices/lead/library/hhi/Mold.pdf (accessed May  9, 2008).
Department of Housing and Urban Development; Department of  Agriculture, Cooperative State Research, Education, and Extension  Service; and University of Wisconsin Healthy Homes Partnership, Help  Yourself to a Healthy Home (Washington, D.C., 2002).  http://www.hud.gov/offices/lead/library/hhi/HYHH_Booklet.pdf (accessed  May 9, 2008).
section_title: Appendix VI: GAO Contact and Staff Acknowledgments
subsections: section_title: Staff Acknowledgments
paragraphs: In addition to the contact named above, Christine Fishkin, Assistant  Director; Krista Breen Anderson; Nancy Crothers; Benjamin Howe;  Richard P. Johnson; Nico Sloss; and Ruth Solomon made key  contributions to this report. Linda Choy; Michael Derr; Alice Feldesman;  Terrance Horner; Armetha Liles; Luann Moy; and Anne Rhodes-Kline also  made important contributions.