MOULDS & MASKS MOISTURE & MAYHEM

1. MOULDS & MASKS MOISTURE & MAYHEM Jim Gauthier, MLT, CIC Infection Control Practitioner February 2005

2. What are Fungi? • A diverse Kingdom of organisms that includes yeasts, moulds and mushrooms. • Found in soil, water, and air. • Derive their nourishment by breaking down organic matter. • Many species reproduce by means of spores.

3. What is Mould? • Fuzzy coating of fungus that grows on food and other surfaces that contain sufficient moisture. • Spores readily dispersed during excavation, demolition and construction.

4. Spores • Need temperature, substrate, and moisture • Wide range of temperatures => 4o to 40o C • Drywall, wood and wood products, ceiling tiles, wallpaper and carpets, dirt crawl spaces • Masonry, fiberglass won’t support if not soiled with other nutrients. • High humidity, flood, leaks, HVAC • Range in size from 1-50 µm

5. Spores • Root like structure in hours • Visible colonization and masses of spores within 3-5 days. • Black, green or grey spotty circular growth or as masses of fine, white, fluffy growth.

6. Mould Growth • Musty, earthy odour, which is the release of metabolic by-products, often present as mould grows

7. So What? • Mould spores can be put into the air when we remove ceiling tiles, renovate, or create dust • Spores less than 10µm can enter alveoli • Residents/patients can get sick • Staff can get sick • Now an issue in Health Care

8. False Ceiling Repair • Done after a leak. • Above IV supplies • Contaminated adhesive tape and arm boards • 6 infected, 2 died

9. Demolition • Ducts, false ceiling, glass fibre insulation • Work on roller-blind casings • 22 cancer patients infected, 18 died.

10. Outside Construction • Road construction • Air conditioner heavily contaminated with Aspergillus spores • 10 cancer patients infected, all 10 died

11. During Construction • Wet fireproofing material installed. • Spores dispersed when the dry fireproofing was disturbed during maintenance or renovation • 8 cancer patients infected, 3 died

12. What Can They Do? • Produce potent mycotoxins • Metabolites that have been identified as toxic agents • Aspergillus, Penicillium, Fusarium, Trichoderma, Memnoniella, and Stachybotrys

13. Stachybotrys chartarum • Greenish-black mould • Likes high cellulose and low nitrogen content (fibreboard, paper, dust, lint) • Currently NO association between it and health symptoms (CDC 2004)

14. Stachybotrys chartarum • Even when hundreds of conidia (asexual spores) seen on direct examination, only 2-3% will be viable • Dead conidia apparently remain toxic for some time, as do conidial fragments

15. Canadian Construction Association (CCA) - 2004 • Legal Overview • Compared to the Asbestos crises of several years ago • Employers must take all reasonable measures to protect the health and safety of workers • Includes a duty to protect against exposure to potentially harmful substances such as mould. • These measures require the immediate and safe removal of any mould growth in buildings • While protecting workers, occupants and surrounding environment.

16. Exposure to Indoor Fungi • Symptoms are vague: • Runny nose, eye irritation, cough, congestion, aggravation of asthma, headache, flu-like symptoms, fatigue, skin rash. • Symptoms may be caused by bacterial or viral pathogens or other allergies. • People with suppressed immune systems may be susceptible to fungal infections as a result of exposure to indoor moulds.

17. Exposure to Indoor Fungi • Current reviews in latest Health Canada document find some relationship between indoor mould and respiratory, allergic or irritation symptoms • There is a published study that found an association between mould exposure at school and childhood asthma

18. Assessment for Mould Visual, Intrusive, Surface • Visual inspection • Great checklist in Appendix A • Concentrate on areas of known water damage, or where odours are noted. • Intrusive Inspection • Peel back baseboards or wallpaper, remove sections of carpet or ceiling tiles, cut holes in walls

19. Assessment for Mould • Intrusive Inspections (Continued) • Remove occupants if possible (esp. infants, asthmatics, compromised immune systems, etc.) • Will need to consider isolated conditions and perhaps negative air enclosures • Investigator wear PPE

20. Assessment for Mould • Surface Testing • Where contamination is evident, it is seldom necessary to test mould-suspect materials (MSM) • 3 types of testing • Bulk or Substrate samples • Tape-lift samples • swabs

21. Assessment for Mould • Bulk or Substrate • Send a sample of MSM • Use a sturdy zip-lock bag. • Clean sampling tool between samples. • Tape-Lift • Clear adhesive tape pressed lightly against MSM • Stick onto clear plastic (zip lock bag works)

22. Assessment for Mould • Swab • Use standard clinical swab • Roll swab against the MSM surface. • Best to check with Laboratory first • Need to make sure they are certified, accredited, and can handle environmental samples.

23. Assessment for Mould • Air Sampling • Not typically required in investigations • Sometimes performed after abatement procedures • Need outside background, pre and post tests.

24. Canadian Standards Association • Z317.13-03. Infection control during construction or renovation of health care facilities • Section 7 – Remedial Measures • 7.2 – Report water leaks and flooding immediately to the managers of the affected area. They shall be responsible for: • Protecting or removing patients • Defining, locating and controlling leaks • Recording the extent of damage to structures, materials and furniture • Implement and monitor remedial measures.

25. Assessment for Mould • Health Canada’s “Fungal contamination in public buildings: Health effects and investigation methods” • Steps to follow that reiterate other documents commented upon.

26. Z317.13-03 • 7.3.1 Investigate by trained maintenance staff or accredited consultants. • 7.3.2 Inspect all concealed spaces, use moisture meter • 7.3.3 Determine if < 48 hours or > 48 hours.

27. Remediation Levels (7.3.4) • Level 1 – small area, less than 1 m2 • Level 2 – medium, 1 to 3 m2 • Level 3 – large area, >3 m2 to 10 m2 • Level 4 – extensive contamination >10 m2 • Level 5 – HVAC or domestic water systems contaminated in any affected area.

28. Remediation Levels • CCA 82 – 3 Levels • Level 1 - < 1 m2 • Level 2 – 1-10 m2 • Level 3 - >10 m2

29. Containment of Contaminants • 7.4.1 – Do not create dust or disperse spores • 7.4.2 – Mist surfaces • 7.4.3 – Seal duct work, diffusers and openings, maintain negative pressure • 7.4.4 – Close and seal doors, windows, and impermeable dust barrier required. • 7.4.5 – Personal Protective Equipment (PPE) required.

30. Abatement • 7.6.2 – Performed by a qualified abatement contractor or by maintenance staff trained in abatement protocols. • 7.6.3 – Remove contaminated materials in a manner to limit dust generation. • 7.6.4 – Wrap in 0.15 mm (6 mil) polyethylene, and seal with tape

31. Abatement • 7.6.5 – Non-removable materials need to be vacuumed with HEPA-filtered vacuum, then scrubbed with detergent solution. • 7.6.6 – All surfaces and materials adjacent to the affected area shall be vacuumed and wet wiped with a mild detergent. • 7.6.7 – If risk of contamination, air ductwork to and from the affected area shall also be vacuumed and wet wiped. All downline filters to be replaced.

32. Level 1 AbatementCCA • Regular building staff • Must be trained in use of PPE and proper clean-up methods • Well informed about the hazards of mould abatement • If history of significant allergic disease (hay fever, asthma, hives) consult with Occupational Physician

33. Level 1 Abatement • Limit access of patients • Especially patients recovering from surgery, infants, elderly, suppressed immune systems, etc. • Use half face piece air purifying respirator fitted with N95 filters as a minimum OR filtering facepiece respiratory (N95 minimum) and suitable eye protection • Fit tested prior to initial use and annually

34. Level 1 Abatement • Disposable coveralls and dust impermeable gloves appropriate for initial work • Water impermeable gloves when applying detergent or disinfectant. • May wear disposable boot covers or clean boots off before leaving the area. • Turn off HVAC and cover openings

35. Level 1 Abatement • Moveable non-porous items within work area shall be cleaned with HEPA vacuum, then cleaning solution, then removed. • Fixed non-porous items shall be HEPA vacuumed, wet wiped, then sealed under polyethylene sheeting, taped in place during remediation.

36. Level 1 Abatement • Place drop sheet if possible. • Dust suppression: tape plastic or duct tape over mouldy material, or lightly mist the material with water. DO NOT dry sweep or dry whisk. • Remove porous materials well beyond the areas of visible contamination; minimum distance is 30 cm.

37. Level 1 Abatement • After bulk removal, HEPA vacuum. • If HEPA vacuum not available, wet wiping is adequate for Level 1 work (CCA 82, pg 24, #11) • Seal waste into 6 mil disposable bags. Wet wipe or clean the bags with a HEPA vacuum and then double bag in a second clean 6 mil nominal bag or suitable sealed container.

38. Level 1 Abatement • Clean equipment (HEPA vacuum and wet wipe). • Waste is good for landfill, if not breaking applicable local or provincial laws (?)! • Wash face and hands, clean half-face resp. • Leave areas dry and free from contamination and debris • Ensure adequately dry before installing new materials.

39. Level II Abatement • Need a health and safety professional experienced in performing microbial investigations as consultant • Competent supervisor must be present during all decontamination work. • USE OUTSIDE AGENCY!!

40. Householder’s Guide • Focuses on reducing moisture in residences • “Renters: report all plumbing leaks and moisture problems immediately to your building owner, manager, or superintendent. In cases where persistent water problems are not addressed, you may want to contact local or provincial health or housing authorities.”

41. Tenants • HOWEVER: I could not find language in the Tenant Protection Act on mould, mold, spores, fungus or water damage clean up. • nor in AB, BC, MB, SK, NB, NF, NS, PEI, PQ • very interesting!

42. Suggestions and Discussion • This could very well be an expensive venture that we must undertake in public buildings • Mould audit similar to the asbestos audits of a few years ago • Mark vacant areas where mould is present, slate for remediation when necessary • Mould in occupied areas needs to be addressed ASAP

43. Suggestions and Discussion • In healthcare, train our maintenance and housekeeping staff to recognize mould, and how to remediate Level 1 volumes • Establish when to culture, and where to send cultures for analysis • Cost of remediation: you want to make sure it is mould! • Need to involve Infection Control and Occupational Health

44. Suggestions and Discussion • Health Canada comments on a safe workplace as being mandated (Hazardous Products Act, the Canada Labour code, Transportation of Dangerous Goods Act), and that we need to look at our legislation, with the input of the designated Medical Officer of Health or Public Health Directors for the area concerned, as there is not good language for air contaminants.

45. Suggestions and Discussion • Train someone regionally as an “expert” • Center for Disaster Recovery in Barrie is certified training school • Have very clear policy and procedure on water clean up, within 48 hours • See “Wheel of Fungus”!

46. Questions?

47. Resources • Health Canada. Construction-related Nosocomial Infections in Patients in Health Care Facilities – can be found at: • http://www.phac-aspc.gc.ca/publicat/ccdr-rmtc/01vol27/27s2/index.html • Canadian Standards Association. Z317.13-03. Infection control during construction or renovation of health care facilities. 2003 • Canadian Construction Association. CCA 82-2004. Mould guidelines for the Canadian construction industry.2004 • http://www.cca-acc.com/documents/electronic/cca82/cca82.pdf • www.cdc.gov/nceh/airpollution/mold/stachy.htm

48. Resources • Center for Disaster Recovery, Barrie, ON • www.centerfordisasterrecovery.com • Fungal contamination in Public Buildings: A guide to recognition and management 1995 • www.hc-sc.gc.ca/hecs-sesc/air_quality/pdf/fungal.pdf • Fungal contamination in Public Buildings: Health effects and investigation methods 2004 • www.hc-sc.gc.ca/hecs-sesc/air_quality/pdf/fungal_contamination.pdf • New York City Department of Health: Guidelines on assessment and remediation of fungi in indoor environments • http://www.nyc.gov/html/doh/html/epi/moldrpt1.html

49. Resources • Canada Mortgage and Housing. Moisture and air, problems and remedies. Pamphlet 61033. • EPA. A brief guide to mold, moisture and your home. • http://www.epa.gov/iaq/molds/images/moldguide.pdf • Tenant Protection Act 1997 • http://192.75.156.68/DBLaws/Statutes/English/97t24_e.htm