Paul J. Dowling

Health effects of indoor fungi

OBJECTIVE To review the nontoxic harmful effects that poor indoor air quality caused by fungi can have on health. DATA SOURCES We searched PubMed for publications related to the various topics discussed in this review, and we relied on our knowledge of the field. STUDY SELECTION Where more than one publication was relevant, we attempted to identify a consensus of the reports and cited the most relevant articles. Priority was given to randomized controlled trials and expert reports when available, although much of the information herein relates to laboratory research. RESULTS Actively growing fungal colonies can release volatile substances that have an unpleasant smell, leading to psychological responses in the occupants such as fatigue and nausea. Symptoms that are likely caused by indoor fungi include respiratory complaints that involve the nose and lungs, eye symptoms, and mucous membrane irritation. These adverse effects can occur by a variety of mechanisms, including IgE-mediated hypersensitivity, fungal infection, irritant reaction to spores or fungal metabolites, and possibly toxic reaction to mycotoxins. CONCLUSIONS Reduced fungal exposure can reasonably be expected to improve health. Removal of moisture from the indoors and proper maintenance of air filters can aid in prevention and elimination of fungi from the home environment. Small areas of present contamination can be cleaned with a dilute bleach solution, which kills viable colonies and removes their mycelia. If fungal contamination is not addressed early, substantial damage can occur, requiring professional remediation. Above all, the individual should not panic at the first sight of fungi growing in the home. Regular inspection and cleaning can prevent many fungus-related problems.

Effectiveness and Tolerability of Zafirlukast for the Treatment of Asthma in Children

OBJECTIVE This study was undertaken to examine the dose-response relationship of zafirlukast (5 to 40 mg BID) and to assess the efficacy and tolerability of the 10-mg BID dose in school-aged children with mild to moderate asthma. BACKGROUND The efficacy and tolerability of zafirlukast, an oral leukotriene-receptor antagonist, has been demonstrated in adolescents and adults aged > or = 12 years. METHODS Data from 2 placebo-controlled, parallel-group, multicenter trials (trial 1, 4-week double-blind; trial 2, 6-week double-blind) were integrated. Children aged 5 to 11 years were randomly assigned to receive zafirlukast 5 mg BID (n = 99), 10 mg BID (n = 205), 20 mg BID (n = 105), 40 mg BID (n = 99), or placebo (n = 206). The primary outcome was change from baseline in forced expiratory volume in 1 second (FEV1) expressed as percent of predicted normal. Secondary outcomes were FEV1 (L), morning and evening peak expiratory flow, peak flow variability, short-acting beta2-agonist use, asthma episode score, and nights awakened by asthma. RESULTS Mean baseline FEV1 was 76.5% of predicted. The greatest improvements were generally seen with zafirlukast 5 mg BID or 10 mg BID, with no additional clinically significant benefits seen at higher doses. The pooled data analysis showed that 10 mg BID compared with placebo significantly improved (P < 0.045) all efficacy outcomes except asthma-episode score and nights awakened with asthma. However, in the subset of children who had > or = 1 night awakened per week at baseline (zafirlukast 10 mg BID = 78; placebo = 86), 10 mg BID significantly reduced nights awakened (P = 0.009) (mean difference from placebo at end point = -0.81 night/wk). All zafirlukast doses were well tolerated and had tolerability profiles that were clinically indistinguishable from placebo. CONCLUSION These results support the effectiveness and tolerability of the 10-mg BID dose of zafirlukast for the prophylaxis and chronic treatment of mild to moderate asthma in children.

Low-cost interventions improve indoor air quality and children's health.

Intervention in the home environment to reduce asthma triggers theoretically improves health outcomes for asthmatic children. Practical benefit from application of these interventions has proven difficult. This single-blind study tested the effectiveness of simple low-cost home interventions in improving health scores of children with asthma. Families with at least one asthmatic child were recruited. Initial health examination, health, and home assessments were conducted and targeted interventions were implemented. Interventions included dehumidification, air filtration, furnace servicing, and high-efficiency furnace filters. When present, gross fungal contamination was remediated. Asthma education was provided along with education in healthy home practices. Follow-up assessments were conducted after 6 months. Health surveys were completed at enrollment and follow-up. This study enrolled 219 children with asthma. Home inspections and interventions were conducted in 181 homes and 83 families completed all phases. Reduction in asthma and allergy-related health scores was shown in follow-up health surveys. Health improvements were significant for cough when heating, ventilation, and air conditioning (HVAC) service and dehumidification were used. Breathing problems were significantly improved for dehumidification, HVAC service, and room air cleaners. Total dust allergen load was reduced for the dehumidification group (p < 0.05). Mold spore counts were reduced one order of magnitude in 25% of the homes. Indoor spore counts adjusted for outdoor spore levels were reduced overall (p < 0.01). Simple low-cost interventions directed to producing cleaner indoor air coupled with healthy home education improve the indoor air quality and health in asthmatic children.

Comparison of indoor fungal spore levels before and after professional home remediation

BACKGROUND Methods for assessing and controlling fungi in the indoor environment have been well documented, but the role of fungal allergen avoidance and respiratory disease control is just beginning to be studied. OBJECTIVE To investigate indoor fungal spore levels to determine if remediation produced reduction of these levels. METHODS The study was performed on homes remediated for excessive fungal load during 2000 to 2002. Homes were included in the study if they had professional fungal remediation. Airborne spore samples were taken both before and after remediation. Slides were mounted with glycerin jelly that contained Calberlas solution. Spores were identified and counted microscopically at a magnification of X 1000. Counts were represented as the number of spores per cubic meter of air. RESULTS Preevaluations and postevaluations were conducted for 17 structures. There were 92 individual collections before remediation and 99 collections after remediation. Mean counts were 131,687 (median, 9461) before remediation and 1291 (median, 409) after remediation. Aspergillus and Penicillium spores (which were counted together) occurred with the highest frequency in preremediation structures (88%). Stachybotrys spores were present in 53% of structures before remediation. Cladosporium spores were found in highest frequency in postremediation collections. Preremediation houses contained at least a 1-log increase in AspergilluslPenicillium spores over outside collections. In postremediation houses, indoor spore counts averaged 18% of outdoor counts. CONCLUSIONS Remediation for indoor fungal spore contamination can significantly reduce spore counts. Indoor collections in preremediation buildings are generally much higher than outdoor counts for critical spore types, including Aspergillus/Penicillium and Stachybotrys. Remediation provides indoor spore levels substantially lower than outdoor counts.

Addressing barriers to emergency anaphylaxis care: from emergency medical services to emergency department to outpatient follow-up

BACKGROUND Anaphylaxis is a systemic life-threatening allergic reaction that presents unique challenges for emergency care practitioners. Allergists and emergency physicians have a history of collaborating to promote an evidence-based, multidisciplinary approach to improve the emergency management and follow-up of patients with or at risk of anaphylaxis. OBJECTIVES To review recent scientific literature about anaphylaxis, discuss barriers to care, and recommend strategies to support improvement in emergency anaphylaxis care. METHODS An expert panel of allergists and emergency physicians was convened by the American College of Allergy, Asthma and Immunology in November 2014 to discuss current knowledge about anaphylaxis, identify opportunities for emergency practitioners and allergists to partner to address barriers to care, and recommend strategies to improve medical management of anaphylaxis along the continuum of care: from emergency medical systems and emergency department practitioners for acute management through appropriate outpatient follow-up with allergists to confirm diagnosis, identify triggers, and plan long-term care. RESULTS The panel identified key barriers to anaphylaxis care, including difficulties in making an accurate diagnosis, low rates of epinephrine administration during acute management, and inadequate follow-up. Strategies to overcome these barriers were discussed and recommendations made for future allergist/emergency physician collaborations, and key messages to be communicated to emergency practitioners were proposed. CONCLUSION The panel recommended that allergists and emergency physicians continue to work in partnership, that allergists be proactive in outreach to emergency care practitioners, and that easy-to-access educational programs and materials be developed for use by emergency medical systems and emergency department practitioners in the training environment and in practice.

The Role of the Environment in Eosinophilic Esophagitis

Eosinophilic esophagitis (EoE) is a chronic, immune-mediated inflammatory disease with incompletely understood pathogenesis. Though disease manifestations were initially ascribed to a delayed reaction to food allergens, emerging evidence suggests that modifiable host factors and environmental allergen exposure may also play critical roles in the pathogenesis and ongoing manifestations of EoE. As with other atopic diseases, lack of early-life exposure to microbial pathogens leads to an immune tolerance defect and reprograms the commensal gut microflora toward a type 2 T helper (Th2) phenotype; the esophageal microbiota, a rich environment consisting of diverse bacterial species, is greatly altered by inflammation. Although multiple early life microbiome-altering factors are associated with EoE development, no causative, direct relationships have been identified. Interestingly, large, cross-sectional analyses of several populations identify an inverse relationship between Helicobacter pylori presence and EoE, likely via virulence factors that downregulate Th2 inflammation, though causality has not been proven. In regard to environmental allergens, some studies support seasonal variation in EoE diagnosis and flares, and EoE can be generated after a large, identifiable aeroallergen exposure. Examples include mouse models of intranasal Aspergillus dosing and following initiation of oral immunotherapy to foods or environmental allergens. Conversely, treatment of allergic rhinoconjunctivitis may improve EoE symptoms, though data is limited to case reports and small series. Unfortunately, biologic therapies for atopic conditions have failed to improve EoE symptoms despite improvement in esophageal eosinophil count, though dupilumab shows promise in ongoing studies. Overall, this chapter shows that EoE pathogenesis is likely multifactorial, and the environment is a key component in our understanding of EoE.