On May 7, 1993, the New York City Department of Health (DOH), the New York City Human Resources Administration (HRA), and the Mt. Sinai Occupational Health Clinic convened an expert panel on Stachybotrys atra in Indoor Environments. The purpose of the panel was to develop policies for medical and environmental evaluation and intervention to address Stachybotrys atra (now known as Stachybotrys chartarum (SC)) contamination. The original guidelines were developed because of mould growth problems in several New York City buildings in the early 1990's. This document revises and expands the original guidelines to include all fungi (mould). It is based both on a review of the literature regarding fungi and on comments obtained by a review panel consisting of experts in the fields of microbiology and health sciences. It is intended for use by building engineers and management, but is available for general distribution to anyone concerned about fungal contamination, such as environmental consultants, health professionals, or the general public.

    We are expanding the guidelines to be inclusive of all fungi for several reasons:

• Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium, Trichoderma, and Memnoniella) in addition to SC can produce potent mycotoxins, some of which are identical to compounds produced by SC. Mycotoxins are fungal metabolites that have been identified as toxic agents. For this reason, SC cannot be treated as uniquely toxic in indoor environments.

• People performing renovations/cleaning of widespread fungal contamination may be at risk for developing Organic Dust Toxic Syndrome (ODTS) or Hypersensitivity Pneumonitis (HP). ODTS may occur after a single heavy exposure to dust contaminated with fungi and produces flu-like symptoms. It differs from HP in that it is not an immune-mediated disease and does not require repeated exposures to the same causative agent. A variety of biological agents may cause ODTS including common species of fungi. HP may occur after repeated exposures to an allergen and can result in permanent lung damage.

• Fungi can cause allergic reactions. The most common symptoms are runny nose, eye irritation, cough, congestion, and aggravation of asthma.

            Fungi are present almost everywhere in indoor and outdoor environments. The most common symptoms of fungal exposure are runny nose, eye irritation, cough, congestion, and aggravation of asthma. Although there is evidence documenting severe health effects of fungi in humans, most of this evidence is derived from ingestion of contaminated foods (i.e., grain and peanut products) or occupational exposures in agricultural settings where inhalation exposures were very high. With the possible exception of remediation to very heavily contaminated indoor environments, such high-level exposures are not expected to occur while performing remedial work.

            There have been reports linking health effects in office workers to offices contaminated with moldy surfaces and in residents of homes contaminated with fungal growth. Symptoms, such as fatigue, respiratory ailments, and eye irritation were typically observed in these cases. Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, fungal contaminants and other bioaerosols, and water-damaged homes), and currently its association with SC is unproven.

       The focus of this guidance document addresses mould contamination of building components (walls, ventilation systems, support beams, etc.) that are chronically moist or water damaged. Occupants should address common household sources of mould, such as mould found in bathroom tubs or between tiles with household cleaners. moldy food (e.g., breads, fruits, etc.) should be discarded.

         Building materials supporting fungal growth must be remediated as rapidly as possible in order to ensure a healthy environment. Repair of the defects that led to water accumulation (or elevated humidity) should be conducted in conjunction with or prior to fungal remediation. Specific methods of assessing and remediating fungal contamination should be based on the extent of visible contamination and underlying damage. The simplest and most expedient remediation that is reasonable, and properly and safely removes fungal contamination, should be used. Remediation and assessment methods are described in this document.

        The use of respiratory protection, gloves, and eye protection is recommended. Extensive contamination, particularly if heating, ventilating, air conditioning (HVAC) systems or large occupied spaces are involved, should be assessed by an experienced health and safety professional and remediated by personnel with training and experience handling environmentally contaminated materials. Lesser areas of contamination can usually be assessed and remediated by building maintenance personnel. In order to prevent contamination from recurring, underlying defects causing moisture buildup and water damage must be addressed. Effective communication with building occupants is an essential component of all remedial efforts.

             Fungi in buildings may cause or exacerbate symptoms of allergies (such as wheezing, chest tightness, shortness of breath, nasal congestion, and eye irritation), especially in persons who have a history of allergic diseases (such as asthma and rhinitis). Individuals with persistent health problems that appear to be related to fungi or other bioaerosol exposure should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures. Decisions about removing individuals from an affected area must be based on the results of such medical evaluation, and be made on a case-by-case basis. Except in cases of widespread fungal contamination that are linked to illnesses throughout a building, building-wide evacuation is not indicated.

        In summary, prompt remediation of contaminated material and infrastructure repair is the primary response to fungal contamination in buildings. Emphasis should be placed on preventing contamination through proper building and HVAC system maintenance and prompt repair of water damage.

        On May 7, 1993, the New York City Department of Health (DOH), the New York City Human Resources Administration (HRA), and the Mt. Sinai Occupational Health Clinic convened an expert panel on Stachybotrys atra in Indoor Environments. The purpose of the panel was to develop policies for medical and environmental evaluation and intervention to address Stachybotrys atra (now known as Stachybotrys chartarum (SC)) contamination. The original guidelines were developed because of mould growth problems in several New York City buildings in the early 1990's. This document revises and expands the original guidelines to include all fungi (mould). It is based both on a review of the literature regarding fungi and on comments obtained by a review panel consisting of experts in the fields of microbiology and health sciences. It is intended for use by building engineers and management, but is available for general distribution to anyone concerned about fungal contamination, such as environmental consultants, health professionals, or the general public.

        This document contains a discussion of potential health effects; medical evaluations; environmental assessments; protocols for remediation; and a discussion of risk communication strategy. The guidelines are divided into four sections:

1. Health Issues; 2. Environmental Assessment; 3. Remediation; and 4. Hazard Communication.

    We are expanding the guidelines to be inclusive of all fungi for several reasons:

• Many fungi (e.g., species of Aspergillus, Penicillium, Fusarium, Trichoderma, and Memnoniella) in addition to SC can produce potent mycotoxins, some of which are identical to compounds produced by SC.^{1, 2, 3, 4} Mycotoxins are fungal metabolites that have been identified as toxic agents. For this reason, SC cannot be treated as uniquely toxic in indoor environments.

• People performing renovations/cleaning of widespread fungal contamination may be at risk for developing Organic Dust Toxic Syndrome (ODTS) or Hypersensitivity Pneumonitis (HP). ODTS may occur after a single heavy exposure to dust contaminated with fungi and produces flu-like symptoms. It differs from HP in that it is not an immune-mediated disease and does not require repeated exposures to the same causative agent. A variety of biological agents may cause ODTS including common species of fungi. HP may occur after repeated exposures to an allergen and can result in permanent lung damage.^{5, 6, 7, 8, 9, 10}

• Fungi can cause allergic reactions. The most common symptoms are runny nose, eye irritation, cough, congestion, and aggravation of asthma.^{11, 12}

     Fungi are present almost everywhere in indoor and outdoor environments. The most common symptoms of fungal exposure are runny nose, eye irritation, cough, congestion, and aggravation of asthma. Although there is evidence documenting severe health effects of fungi in humans, most of this evidence is derived from ingestion of contaminated foods (i.e., grain and peanut products) or occupational exposures in agricultural settings where inhalation exposures were very high.^{13, 14} With the possible exception of remediation to very heavily contaminated indoor environments, such high level exposures are not expected to occur while performing remedial work.¹⁵

         There have been reports linking health effects in office workers to offices contaminated with moldy surfaces and in residents of homes contaminated with fungal growth.^{12, 16, 17, 18, 19, 20} Symptoms, such as fatigue, respiratory ailments, and eye irritation were typically observed in these cases.

   Some studies have suggested an association between SC and pulmonary hemorrhage/hemosiderosis in infants, generally those less than six months old. Pulmonary hemosiderosis is an uncommon condition that results from bleeding in the lungs. The cause of this condition is unknown, but may result from a combination of environmental contaminants and conditions (e.g., smoking, other microbial contaminants, and water-damaged homes), and currently its association with SC is unproven.^{21, 22, 23}

      The focus of this guidance document addresses mould contamination of building components (walls, ventilation systems, support beams, etc.) that are chronically moist or water damaged. Occupants should address common household sources of mould, such as mould found in bathroom tubs or between tiles with household cleaners. moldy food (e.g., breads, fruits, etc.) should be discarded.

    In all situations, the underlying cause of water accumulation must be rectified or fungal growth will recur. Any initial water infiltration should be stopped and cleaned immediately. An immediate response (within 24 to 48 hours) and thorough clean up, drying, and/or removal of water damaged materials will prevent or limit mould growth. If the source of water is elevated humidity, relative humidity should be maintained at levels below 60% to inhibit mould growth.³¹ Emphasis should be on ensuring proper repairs of the building infrastructure, so that water damage and moisture buildup does not recur.

    Five different levels of abatement are described below. The size of the area impacted by fungal contamination primarily determines the type of remediation. The sizing levels below are based on professional judgement and practicality; currently there is not adequate data to relate the extent of contamination to frequency or severity of health effects. The goal of remediation is to remove or clean contaminated materials in a way that prevents the emission of fungi and dust contaminated with fungi from leaving a work area and entering an occupied or non-abatement area, while protecting the health of workers performing the abatement. The listed remediation methods were designed to achieve this goal, however, due to the general nature of these methods it is the responsibility of the people conducting remediation to ensure the methods enacted are adequate. The listed remediation methods are not meant to exclude other similarly effective methods. Any changes to the remediation methods listed in these guidelines, however, should be carefully considered prior to implementation.

    Non-porous (e.g., metals, glass, and hard plastics) and semi-porous (e.g., wood, and concrete) materials that are structurally sound and are visibly moldy can be cleaned and reused. Cleaning should be done using a detergent solution. Porous materials such as ceiling tiles and insulation, and wallboards with more than a small area of contamination should be removed and discarded. Porous materials (e.g., wallboard, and fabrics) that can be cleaned, can be reused, but should be discarded if possible. A professional restoration consultant should be contacted when restoring porous materials with more than a small area of fungal contamination. All materials to be reused should be dry and visibly free from mould. Routine inspections should be conducted to confirm the effectiveness of remediation work.

    The use of gaseous, vapor-phase, or aerosolized biocides for remedial purposes is not recommended. The use of biocides in this manner can pose health concerns for people in occupied spaces of the building and for people returning to the treated space if used improperly. Furthermore, the effectiveness of these treatments is unproven and does not address the possible health concerns from the presence of the remaining non-viable mould. For additional information on the use of biocides for remedial purposes, refer to the American Conference of Governmental Industrial Hygienists' document, "Bioaerosols: Assessment and Control."

3.1 Level I: Small Isolated Areas (10 sq. ft or less) - e.g., ceiling tiles, small areas on walls

1. Remediation can be conducted by regular building maintenance staff. Such persons should receive training on proper clean up methods, personal protection, and potential health hazards. This training can be performed as part of a program to comply with the requirements of the OSHA Hazard Communication Standard (29 CFR 1910.1200).

2. Respiratory protection (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended. Gloves and eye protection should be worn.

3. The work area should be unoccupied. Vacating people from spaces adjacent to the work area is not necessary but is recommended in the presence of infants (less than 12 months old), persons recovering from recent surgery, immune suppressed people, or people with chronic inflammatory lung diseases (e.g., asthma, hypersensitivity pneumonitis, and severe allergies).

4. Containment of the work area is not necessary. Dust suppression methods, such as misting (not soaking) surfaces prior to remediation, are recommended.

5. Contaminated materials that cannot be cleaned should be removed from the building in a sealed plastic bag. There are no special requirements for the disposal of moldy materials.

6. The work area and areas used by remedial workers for egress should be cleaned with a damp cloth and/or mop and a detergent solution.

7. All areas should be left dry and visibly free from contamination and debris.

3.2 Level II: Mid-Sized Isolated Areas (10 - 30 sq. ft.) - e.g., individual wallboard panels.

1. Remediation can be conducted by regular building maintenance staff. Such persons should receive training on proper clean up methods, personal protection, and potential health hazards. This training can be performed as part of a program to comply with the requirements of the OSHA Hazard Communication Standard (29 CFR 1910.1200).

2. Respiratory protection (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended. Gloves and eye protection should be worn.

3. The work area should be unoccupied. Vacating people from spaces adjacent to the work area is not necessary but is recommended in the presence of infants (less than 12 months old), persons having undergone recent surgery, immune suppressed people, or people with chronic inflammatory lung diseases (e.g., asthma, hypersensitivity pneumonitis, and severe allergies).

4. The work area should be covered with a plastic sheet(s) and sealed with tape before remediation, to contain dust/debris.

5. Dust suppression methods, such as misting (not soaking) surfaces prior to remediation, are recommended.

6. Contaminated materials that cannot be cleaned should be removed from the building in sealed plastic bags. There are no special requirements for the disposal of moldy materials.

7. The work area and areas used by remedial workers for egress should be HEPA vacuumed (a vacuum equipped with a High-Efficiency Particulate Air filter) and cleaned with a damp cloth and/or mop and a detergent solution.

8. All areas should be left dry and visibly free from contamination and debris.

3.3 Level III: Large Isolated Areas (30 - 100 square feet) - e.g., several wallboard panels.

A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for the project.

    The following procedures at a minimum are recommended:

1. Personnel trained in the handling of hazardous materials and equipped with respiratory protection, (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended. Gloves and eye protection should be worn.

2. The work area and areas directly adjacent should be covered with a plastic sheet(s) and taped before remediation, to contain dust/debris.

3. Seal ventilation ducts/grills in the work area and areas directly adjacent with plastic sheeting.

4. The work area and areas directly adjacent should be unoccupied. Further vacating of people from spaces near the work area is recommended in the presence of infants (less than 12 months old), persons having undergone recent surgery, immune suppressed people, or people with chronic inflammatory lung diseases (e.g., asthma, hypersensitivity pneumonitis, and severe allergies).

5. Dust suppression methods, such as misting (not soaking) surfaces prior to remediation, are recommended.

6. Contaminated materials that cannot be cleaned should be removed from the building in sealed plastic bags. There are no special requirements for the disposal of moldy materials.

7. The work area and surrounding areas should be HEPA vacuumed and cleaned with a damp cloth and/or mop and a detergent solution.

8. All areas should be left dry and visibly free from contamination and debris.

    If abatement procedures are expected to generate a lot of dust (e.g., abrasive cleaning of contaminated surfaces, demolition of plaster walls) or the visible concentration of the fungi is heavy (blanket coverage as opposed to patchy), then it is recommended that the remediation procedures for Level IV are followed.

3.4 Level IV: Extensive Contamination (greater than 100 contiguous square feet in an area)

A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for the project. The following procedures are recommended:

1. Personnel trained in the handling of hazardous materials equipped with:

   1. Full-face respirators with high efficiency particulate air (HEPA) cartridges

   2. Disposable protective clothing covering both head and shoes

   3. Gloves

2. Containment of the affected area:

   1. Complete isolation of work area from occupied spaces using plastic sheeting sealed with duct tape (including ventilation ducts/grills, fixtures, and any other openings)

   2. The use of an exhaust fan with a HEPA filter to generate negative pressurization

   3. Airlocks and decontamination room

3. Vacating people from spaces adjacent to the work area is not necessary but is recommended in the presence of infants (less than 12 months old), persons having undergone recent surgery, immune suppressed people, or people with chronic inflammatory lung diseases (e.g., asthma, hypersensitivity pneumonitis, and severe allergies).

4. Contaminated materials that cannot be cleaned should be removed from the building in sealed plastic bags. The outside of the bags should be cleaned with a damp cloth and a detergent solution or HEPA vacuumed in the decontamination chamber prior to their transport to uncontaminated areas of the building. There are no special requirements for the disposal of moldy materials.

5. The contained area and decontamination room should be HEPA vacuumed and cleaned with a damp cloth and/or mop with a detergent solution and be visibly clean prior to the removal of isolation barriers.

6. Air monitoring should be conducted prior to occupancy to determine if the area is fit to reoccupy.

3.5 Level V: Remediation of HVAC Systems

3.5.1 A Small Isolated Area of Contamination (<10 square feet) in the HVAC System

1. Remediation can be conducted by regular building maintenance staff. Such persons should receive training on proper clean up methods, personal protection, and potential health hazards. This training can be performed as part of a program to comply with the requirements of the OSHA Hazard Communication Standard (29 CFR 1910.1200).

2. Respiratory protection (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended. Gloves and eye protection should be worn.

3. The HVAC system should be shut down prior to any remedial activities.

4. The work area should be covered with a plastic sheet(s) and sealed with tape before remediation, to contain dust/debris.

5. Dust suppression methods, such as misting (not soaking) surfaces prior to remediation, are recommended.

6. Growth supporting materials that are contaminated, such as the paper on the insulation of interior lined ducts and filters, should be removed. Other contaminated materials that cannot be cleaned should be removed in sealed plastic bags. There are no special requirements for the disposal of moldy materials.

7. The work area and areas immediately surrounding the work area should be HEPA vacuumed and cleaned with a damp cloth and/or mop and a detergent solution.

8. All areas should be left dry and visibly free from contamination and debris.

9. A variety of biocides are recommended by HVAC manufacturers for use with HVAC components, such as, cooling coils and condensation pans. HVAC manufacturers should be consulted for the products they recommend for use in their systems.

3.5.2 Areas of Contamination (>10 square feet) in the HVAC System

A health and safety professional with experience performing microbial investigations should be consulted prior to remediation activities to provide oversight for remediation projects involving more than a small isolated area in an HVAC system. The following procedures are recommended:

1. Personnel trained in the handling of hazardous materials equipped with:

   1. Respiratory protection (e.g., N95 disposable respirator), in accordance with the OSHA respiratory protection standard (29 CFR 1910.134), is recommended.

   2. Gloves and eye protection

   3. Full-face respirators with HEPA cartridges and disposable protective clothing covering both head and shoes should be worn if contamination is greater than 30 square feet.

2. The HVAC system should be shut down prior to any remedial activities.

3. Containment of the affected area:

   1. Complete isolation of work area from the other areas of the HVAC system using plastic sheeting sealed with duct tape.

   2. The use of an exhaust fan with a HEPA filter to generate negative pressurization.

   3. Airlocks and decontamination room if contamination is greater than 30 square feet.

4. Growth supporting materials that are contaminated, such as the paper on the insulation of interior lined ducts and filters, should be removed. Other contaminated materials that cannot be cleaned should be removed in sealed plastic bags. When a decontamination chamber is present, the outside of the bags should be cleaned with a damp cloth and a detergent solution or HEPA vacuumed prior to their transport to uncontaminated areas of the building. There are no special requirements for the disposal of moldy materials.

5. The contained area and decontamination room should be HEPA vacuumed and cleaned with a damp cloth and/or mop and a detergent solution prior to the removal of isolation barriers.

6. All areas should be left dry and visibly free from contamination and debris.

7. Air monitoring should be conducted prior to re-occupancy with the HVAC system in operation to determine if the area(s) served by the system are fit to reoccupy.

8. A variety of biocides are recommended by HVAC manufacturers for use with HVAC components, such as, cooling coils and condensation pans. HVAC manufacturers should be consulted for the products they recommend for use in their systems.

    In summary, the prompt remediation of contaminated material and infrastructure repair must be the primary response to fungal contamination in buildings. The simplest and most expedient remediation that properly and safely removes fungal growth from buildings should be used. In all situations, the underlying cause of water accumulation must be rectified or the fungal growth will recur. Emphasis should be placed on preventing contamination through proper building maintenance and prompt repair of water damaged areas.

    Widespread contamination poses much larger problems that must be addressed on a case-by-case basis in consultation with a health and safety specialist. Effective communication with building occupants is an essential component of all remedial efforts. Individuals with persistent health problems should see their physicians for a referral to practitioners who are trained in occupational/environmental medicine or related specialties and are knowledgeable about these types of exposures.

    The New York City Department of Health would like to thank the following individuals and organizations for participating in the revision of these guidelines. Please note that these guidelines do not necessarily reflect the opinions of the participants nor their organizations.

Name		Company/Institution
Dr. Susan Klitzman		Hunter College
Dr. Philip Morey		AQS Services, Inc
Dr. Donald Ahearn		Georgia State University
Dr. Sidney Crow		Georgia State University
Dr. J. David Miller		Carleton University
Dr. Bruce Jarvis		University of Maryland at College Park
Mr. Ed Light		Building Dynamics, LLC
Dr. Chin Yang		P&K Microbiology Services, Inc
Dr. Harriet Burge		Harvard School of Public Health
Dr. Dorr Dearborn		Rainbow Children's Hospital
Mr. Eric Esswein		National Institute for Occupational Safety and Health
Dr. Ed Horn		The New York State Department of Health
Dr. Judith Schreiber		The New York State Department of Health
Mr. Gregg Recer		The New York State Department of Health
Dr. Gerald Llewellyn		State of Delaware, Division of Public Health
Mr. Daniel Price		Interface Research Corporation
Ms. Sylvia Pryce		The NYC Citywide Office of Occupational Safety and Health
Mr. Armando Chamorro		Ambient Environmental
Ms. Marie-Alix d'Halewyn		Laboratoire de santé publique du Québec
Dr. Elissa A. Favata		Environmental and Occupational Health Associates
Dr. Harriet Ammann		Washington State Department of Health
Mr. Terry Allan		Cuyahoga County Board of Health

    We would also like to thank the many others who offered opinions, comments, and assistance at various stages during the development of these guidelines.

    Christopher D'Andrea, M.S. of the Environmental and Occupational Disease Epidemiology Unit, was the editor of this document.