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Environmental Factors and Asthma What We Learned
from Epidemiological Studies An Issue of Immunology
and Allergy Clinics 1st Edition Mark Eisner Digital
Instant Download
Author(s): Mark Eisner
ISBN(s): 9781416063094, 1416063099
Edition: 1
File Details: PDF, 2.17 MB
Year: 2008
Language: english
 Immunol Allergy Clin N Am
28 (2008) xiii–xiv

Foreword
Environmental Factors in Asthma

Rafeul Alam, MD, PhD

Consulting Editor

Whether you take the biblical quotationd‘‘for dust you are and to dust
you will return’’ (Genesis 3:19)dor the theory of evolution, which implies
that environmental changes triggered the biological evolution, it is all about
environment. We as biologists have recognized the power of genes ever since
Mendel demonstrated the principles of genetic inheritance, and Watson and
Crick resolved the structure and beauty of the double helix. The driving
power of genes in the expression of a phenotype is undeniable. Nonetheless,
phenotype is not the same as genotype, and we are yet to fully understand
the complexity of the gene–environment interaction. Our simple paradigm
of promoter-driven exon-based gene expression is losing its ground. We
now understand that the expression of a gene is far more complex. Gene ex-
pression is controlled by proximal and distant enhancers and silencers, epi-
genetic modulation of the gene locus, secondary regulation by microRNA,
gene splicing, single nucleotide polymorphism, and other factors. Many of
the foregoing processes are influenced by the environment.
Asthma, being a polygenic disease, is far more susceptible to environmen-
tal changes. Thus, research in the environmental aspect of asthma is very im-
portant. A comprehensive understanding of the environmental contribution
to asthma requires population-based case control and prospective epidemi-
ologic studies, which are extremely difficult to conduct. Nonetheless, signif-
icant progress has been made in this field. We have observed continued
evolution of the hygiene hypothesis. We have a better understanding of

0889-8561/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.iac.2008.04.002 immunology.theclinics.com
xiv FOREWORD

indoor pollution. We recognize the complex biologic effect of indoor aller-

gens. To elaborate on the complexity of environmental factors, Dr. Mark
Eisner, a leader in the field, has invited some of the top experts to contribute
to this issue. The issue addresses such important areas as indoor allergens,
indoor and outdoor pollution, hygiene hypothesis dealing with microbial en-
vironment, social environment that includes diet and obesity, and others.
This will be an exciting reading.

Rafeul Alam, MD, PhD

Division of Allergy and Immunology
National Jewish Medical and Research Center
University of Colorado at Denver Health Sciences Center
1400 Jackson Street
Denver, CO 80206, USA
E-mail address: [email protected]
 Immunol Allergy Clin N Am
28 (2008) xv–xvi

Preface

Mark D. Eisner, MD, MPH

Guest Editor

The morbidity and mortality from asthma have increased greatly during
the past few decades in the United States and most developed countries.
Although recent developments in genetics have provided exciting break-
throughs in airway disease, genetic factors, by themselves, cannot explain
the dramatic increases in asthma prevalence and severity. Dramatic changes
in the environment have occurred concurrently with the asthma epidemic,
raising the possibility that environmental factors may be responsible for
the increased burden of asthma. Indeed, the alterations of the indoor and
outdoor environment are dramatic features of the twentieth and twenty-first
centuries. Changes in diet, body composition, and workplace conditions
have also occurred. In this issue of the Immunology and Allergy Clinics of
North America, we review recent epidemiologic studies that implicate the
environment as a cause of asthma and its exacerbation.
The term ‘‘environment’’ is broad and all encompassing. Indeed, it re-
flects all that is external to the human organism. For many, the term ‘‘envi-
ronment’’ connotes the outdoor environment and its pollution by traffic,
other sources of combustion, and industrial contamination. But for most
residents of industrialized countries, the majority of time, in excess of
90%, is spent indoors. Consequently, the indoor environment, which in-
cludes homes, schools, workplaces, and other public places, becomes
especially important. Although it is true that the outdoor (ambient)
environment greatly influences the indoor one by entrainment of air and
other substances, there are unique point sources of pollution, allergen expo-
sure, and viral infection indoors. And finally, the social environment, which
0889-8561/08/$ - see front matter Ó 2008 Elsevier Inc. All rights reserved.
doi:10.1016/j.iac.2008.04.001 immunology.theclinics.com
xvi PREFACE

reflects the broader context of our lives, may have important influences on
asthma.
Randomized controlled trials have become the gold standard for address-
ing many problems in clinical medicine and health. But such trials are not
suited to studying most of the effects of environmental exposures on health.
Although short-term exposure studies are conducted in highly controlled en-
vironments, they provide limited insight into the development of chronic
diseases such as asthma, which have a long induction period (ie, develop
over a long period of time). Ethical and logistic concerns preclude random-
izing human subjects to potentially hazardous exposures over a longer time
period. Therefore, epidemiologic methods are the best ones for assessing the
impact of environmental exposures on health outcomes, such as asthma and
other respiratory diseases.
In this issue, we review the evidence that exposures to indoor pollution
(passive smoking, indoor combustion), other indoor exposures (allergens,
viral infections, occupational exposures, dampness, mold), and outdoor pol-
lution (traffic, other ambient pollution) are important factors for the devel-
opment and clinical course of asthma. The issue also considers the social
environment and how it influences asthma status. The impact of diet and
obesity, which have changed markedly during the past several decades,
may also contribute substantively to the asthma epidemic. And living on
a farm, with exposure to microbes and allergens, has fascinating, and some-
times counterintuitive, effects on asthma induction and course. Finally, an
article on asthma and the inner city integrates the issues of pollutant and al-
lergen exposure that often occur concurrently in the urban environment.
Ultimately, the goal of epidemiology and public health is preventiondin
this case, prevention of asthma incidence and exacerbation. This issue eluci-
dates the impact of the environment, defined broadly, on asthma with the
goal of highlighting possible areas in which exposure prevention or remedi-
ation might decrease the burden of asthma.

Mark D. Eisner, MD, MPH

University of California San Francisco
505 Parnassus Avenue, M1097
San Francisco, CA 94143, USA
E-mail address: [email protected]
 Immunol Allergy Clin N Am
28 (2008) 485–505

Dampness and Mold in the Indoor

Environment: Implications for Asthma
N.M. Sahakian, MD, MPH*, J.-H. Park, ScD, CIH,
J.M. Cox-Ganser, PhD
Centers for Disease Control and Prevention, National Institute of Occupational Health
and Safety, Division of Respiratory Disease Studies, 1095 Willowdale Road,
MS-H2800, Morgantown, WV 26505, USA

The National Institute for Occupational Safety and Health receives

weekly requests to help with issues of indoor environmental quality in rela-
tion to illness in nonindustrial workplaces, such as office buildings and
schools. Since the mid-1990s, there has been a marked increase in the num-
ber of these requests to the point where in 2007 they represented 57% of the
total of 390 requests for evaluation of the workplace in relation to health
and safety issues. As an example of requests concerning work-related
asthma, from January 2007 through December 2007, there were 39 requests
in relation to asthma, 34 (87%) from nonindustrial workplaces with workers
concerned about indoor environmental quality. Of these 34 requests,
23 (68%) listed dampness or mold as exposures of concern. Thus, asthma
in the nonindustrial environment accounts for the majority of the public’s
concern for possible work-related asthma, and requesters have made the
association between their work-related asthma symptoms and damp/moldy
environments. A recent calculation estimates that 21% (95% confidence
interval [CI], 12%–29%) of current asthma in the United States is attribut-
able to dampness/mold in homes [1].
This article presents epidemiologic findings pertinent to asthma and
asthma-like symptoms in relation to exposure to dampness/mold in homes,
schools, and workplaces. With regard to specific agents found in damp indoor
environments that may play a role in asthma, it concentrates on mold (used
synonymously with fungi) and includes some findings on bacteria. The litera-
ture on asthma in relation to dust mite or cockroach allergens is not addressed.

The findings and conclusions in this report are those of the authors and do not necessar-
ily represent the views of the National Institute for Occupational Safety and Health.
* Corresponding author.
E-mail address: [email protected] (N.M. Sahakian).

0889-8561/08/$ - see front matter. Published by Elsevier Inc.

doi:10.1016/j.iac.2008.03.009 immunology.theclinics.com
486 SAHAKIAN et al

Reviews of the epidemiologic literature up to 2003

A European review (NORDDAMP) of well-designed epidemiologic stud-
ies published prior to July 1998 found that odds ratios (ORs) for cough,
wheeze, and asthma associated with indoor dampness ranged from 1.4 to
2.2 [2]. A subsequent review (EUROEXPO) of studies published from
1998 to 2000 confirmed indoor dampness as a risk factor for health effects,
regardless of atopic status. The investigators concluded that additional pro-
spective studies were needed [3].
In the United States, the Centers for Disease Control and Prevention
asked the Institute of Medicine (IOM) to complete a review of the scientific
literature. The IOM committee reviewed studies published up to late 2003
believed influential in shaping the scientific understanding of dampness-
associated health effects [4]. With respect to asthma and asthma-related
symptoms, the IOM found that there was sufficient evidence for associations
between exposure to damp indoor environments or mold or other agents in
damp indoor environments and cough, wheeze, and asthma symptoms in
asthmatic persons, and limited or suggestive evidence for associations
with asthma development and dyspnea. They concluded that excessive in-
door dampness is a public health problem and that prevention or reduction
of this condition should be a public health goal. Among the research needs
formulated by the committee were improved characterization of dampness-
related microbial emissions and chemical emissions from building materials
and furnishings and their roles in adverse health outcomes; studies on inter-
action effects of multiple exposure factors in damp indoor environments;
and studies on intervention effectiveness.

Meta-analysis in 2007
A meta-analysis of 33 peer-reviewed epidemiologic studies on respiratory
health outcomes and home dampness or mold included studies published
from 1989 to 2006 [5]. The estimated OR for cough in adults was 1.52
(95% CI, 1.18–1.96); for cough in children 1.75 (95% CI, 1.56–1.96); for
wheeze in adults 1.39 (95% CI, 1.04–1.85); for wheeze in children 1.53
(95% CI, 1.39–1.68); for current asthma 1.56 (95% CI, 1.30–1.86); for
ever-diagnosed asthma 1.37 (95% CI, 1.23–1.53); and for asthma develop-
ment 1.34 (95% CI, 0.86–2.10). The investigators estimated that home
dampness or mold is associated with a 30% to 50% increase in respiratory
health outcomes.

Dampness/mold and asthma developmentdrecent publications

Recent research not included in the 2004 IOM report has increased the
body of evidence regarding the association between dampness and asthma
development (Tables 1 and 2).
 DAMPNESS AND MOLD IN THE INDOOR ENVIRONMENT 487

Adults
In a study that investigated occupational exposures, researchers reviewed
medical records at clinics in a Swedish town covering a 1.5-year period to
identify cases of newly diagnosed asthma among 20 to 65 year olds [6]. Con-
trols were randomly selected from the Swedish population registry, lived in
the same town, and were matched by age and gender to cases. Response
rates and study numbers for cases and controls were 90% (n ¼ 120) and
84% (n ¼ 446), respectively. The OR (adjusted for occupational exposure
to dust, fumes, or vapors, childhood allergy symptoms, and ever smoking)
for workplace exposure to building mold or moisture damage that lasted
3 or more years and occurred before the year of asthma diagnosis (for cases)
or referent time (for controls) was 4.7 (95% CI, 1.5–14.3). Because this study
included agricultural and maintenance workers whose exposure may differ
in intensity and type from office workers in damp buildings, caution should
be exercised when applying these findings to workers of nonindustrial in-
door environments.
A study by Gunnbjörnsdóttir and colleagues used data from the 1990–1994
European Community Respiratory Health Surveys (ECRHS) and a follow-
up survey conducted in 1999–2001 [7]. Participants from four Nordic coun-
tries were 20 to 44 years old at the time of the initial survey. Response rates
and study numbers for the initial and follow-up surveys were 84% (n ¼
21,802) and 74% (n ¼ 16,190). New-onset asthma was defined as an asthma
attack or use of asthma medications during the past 12 months on the second
survey with negative responses to both of these questions on the first survey.
The OR (adjusted for age, study center, gender, body mass index, rhinitis,
smoking status, type of housing, age of building, and socioeconomic status)
for the association between the presence of home dampness anytime between
the two surveys and new-onset asthma was 1.13 (95% CI, 0.92–1.40) and thus
did not quite meet statistical significance. Associations for new-onset asthma
symptoms were significant. Researchers also investigated the remission of
asthma-like symptoms and found that presence of home dampness in-
between the two surveys significantly decreased remission of nocturnal dysp-
nea and nocturnal cough. Analysis of a subset (Swedish subjects, n ¼ 1854) of
second survey, also by Gunnbjörnsdóttir and colleagues, participants
demonstrated significant positive associations between home dampness
and dyspnea at rest, dyspnea after exertion, and nocturnal dyspnea [8].
A Finnish population-based incident case-control study compared 521
adults, who had newly diagnosed asthma (defined as reversible airways ob-
struction with at least one asthma-like symptom) identified over a 2.5-year
period, to 932 randomly selected controls who did not have asthma [9].
Response rates for cases and controls were 90% and 80%, respectively.
Cases and controls were 21 to 63 years old and lived within the same hospi-
tal district in South Finland. Workplace wall-to-wall carpeting and work-
place mold independently increased the risk for new-onset asthma.
Table 1

488
Epidemiologic studies investigating an association between indoor dampness or mold and new-onset asthma or new-onset asthma-like symptoms that use
odds ratios as a measure of risk
Reference Study design Environmental exposure Health outcome Odds ratio (95% CI)
Adults
Flodin and Longitudinal case-control study Reported workplace dampness New-onset physician-diagnosed 4.7 (1.5–14.3)
Jönsson [6] (20–65 years old) (mold or moisture damage)a asthma at age 20–65 years

Gunnbjörnsdóttir Prospective study with a 7.9-year Reported dampness (water New-onset asthma attack 1.1 (0.9–1.4)
et al [7] follow-up period (mean age damage, leakage, or mold or current use of asthma
at follow up: 40 years) growth) in the homeb medicationsc
New-onset wheezec 1.3 (1.1–1.5)
New-onset nocturnal dyspneac 1.3 (1.1–1.6)
New-onset nocturnal coughc

SAHAKIAN
1.3 (1.1–1.4)

Jaakkola et al [9] Population-based incident Reported visible mold or mold New-onset physician-diagnosed
case-control study odor at workc and asthma with both reversible

et al
(21–63 years old) – No wall-to-wall carpet at work airways obstruction and 1.4 (0.9–2.1)
– Wall-to-wall carpet at work a history of at least one 4.6 (1.1–19.4)
asthma-like symptom
Children
Wickman et al [12] Prospective study of a birth Reported water damage, Three or more episodes of 1.7 (1.3–2.4)
cohort from age 2 months windowpane condensation, wheezing after age 3 months
to 2 years of age visible mold, or mold odor when and either use of inhaled steroids
child was 2 months of age or symptoms suggestive of
bronchial hyper-reactivity

Emenius et al [13] Nested case-control study of One sign of dampness based Three or more episodes of 1.3 (0.8–2.2)
a birth cohort (2 years old) on home inspection wheezing after age 3 months
Three or more signs of dampness and either use of inhaled 2.7 (1.3–5.4)
based on home inspection steroids or symptoms suggestive
of bronchial hyper-reactivity
Pekkanen et al [15] Population-based incident Mold odor based on current New-onset physician-diagnosed 4.1 (0.6–26.0)
case-control study home inspection asthma or new referral
(1–7 years old) Visible mold based on current to hospital after two or 1.2 (0.7–2.1)
home inspection more attacks of wheezing
Visible mold in main living 2.6 (1.2–5.8)
area based on current
home inspection
Water damage in main living 2.2 (1.2–4.0)

DAMPNESS AND MOLD IN THE INDOOR ENVIRONMENT

area based on current
home inspection
a
Present for 3 or more years and occurred at least 3 years before year of asthma diagnosis.
b
Present any time in between the initial and follow-up survey.
c
Present during the past year.

489
 490
Table 2
Epidemiologic studies investigating an association between indoor dampness or mold and new-onset asthma that use incidence rate ratio as a measure of risk
Incidence
rate ratio
Reference Study design Environmental exposure (95% CI)
Adults
Cox-Ganser et al [10] Cross-sectional study with information on Office building with water damage 7.5 (no CI)
dates of hire and asthma diagnosis and mold contamination based
(mean age 46 years) on building inspection

SAHAKIAN
White et al [11] Cross-sectional study with information on School building with evidence of water 8.5 (no CI)
dates of hire and asthma diagnosis damage and mold contamination
(mean age 48 years) based on building inspection

et al
Children
Jaakkola et al [14]a Population-based cohort study with Reported mold odor in the homeb 2.4 (1.1–5.6)
a 6-year follow-up period (1–7 years Reported visible mold in the homeb 0.6 (0.2–1.7)
old at baseline) Reported moisture on surfaces 0.9 (0.5–1.5)
in the homeb
Reported water damage in the homeb 1.0 (0.4–2.3)
Any of above dampness indicators 1.0 (0.7–1.5)
a
Cited in Fisk WJ, Lei-Gomez Q, Mendell MJ. Meta-analyses of the associations of respiratory health effects with dampness and mold in homes. Indoor
Air 2007;17:284–96.
b
Present during the past year at time of initial survey.
 DAMPNESS AND MOLD IN THE INDOOR ENVIRONMENT 491

Workplace wall-to-wall carpet together with workplace mold further in-

creased the risk for new-onset asthma. Results were adjusted for gender,
age, education, personal smoking, environmental tobacco smoke, water
damage, and damp spots at home. It is possible that carpets acted as a res-
ervoir for moisture and related contaminants.
Two cross-sectional studies of United States office and school employees
who worked in buildings with water damage and mold contamination found
postoccupancy adult-onset asthma incidence densities to be 7.5 and 8.5 times
greater than preoccupancy incidence densities, respectively [10,11]. Al-
though, incidence rate ratios (IRRs) were not adjusted for demographic
variables, pre- and postoccupancy asthma incidence densities were calcu-
lated for the same group of participants. These studies support a temporal
association, which is important in establishing a causal association of expo-
sure with disease.

Children
A birth cohort study of 4089 Swedish children at 2 months old and 1 and
2 years old found a positive association between damp home environment
and asthma development 1.74 (95% CI, 1.28–2.39), adjusted for gender, pa-
rental history of allergic disease, socioeconomic status, maternal age, exclu-
sive breastfeeding, maternal smoking, pet ownership, and age of building
[12]. Data on damp home environment were taken from the first question-
naire when the children were 2 months old. Asthma was defined as at least
three episodes of wheezing between 3 months and 2 years of age, in combi-
nation with treatment of inhaled glucocorticoids or signs of hyperreactivity
without upper-respiratory infection. In a subsequent nested case-control
study of the same birth cohort, 181 children who met the case definition
were compared to 359 age-matched healthy controls [13]. Information on
damp indoor conditions came from the baseline questionnaire and from
home inspections in the first winter season after recruitment into the case-
control study. There were consistent positive associations between indica-
tors of dampness/mold in the home and being a case. A strong finding
was that there was an increasing risk for recurrent wheezing with an increas-
ing number of indicators of dampness found during the home inspections:
one indicator of dampness was associated with an OR of 1.3 (95% CI,
0.8–2.2), whereas having three or more dampness indicators was associated
with an OR of 2.7 (95% CI, 1.3–5.4).
A cohort study of randomly selected children from the Finnish popula-
tion registry used results from a survey at age 1 to 7 years and another sur-
vey 6 years later [14]. Response rates and study numbers for the initial and
subsequent surveys were 80% (n ¼ 2568) and 77% (n ¼ 1984), respectively.
Children were considered exposed if mold odor, visible mold, dampness, or
water damage had been reported in the home prior to the baseline study.
The IRR for asthma comparing children exposed (n ¼ 384) and nonexposed
492 SAHAKIAN et al

(n ¼ 1532) to mold odor was 2.44 (95% CI, 1.07–5.60) after adjustment for
age, gender, duration of breastfeeding, parental education, single parent,
maternal smoking during pregnancy, environmental tobacco smoke expo-
sure, gas cooking, presence of furry or feathery pets, and type of child
care. One of the major strengths of this study was its prospective study de-
sign, which eliminated over-reporting of pre-existing home mold based on
newly diagnosed asthma and provided evidence for a temporal relationship
between home mold and asthma.
Other Finnish researchers conducted a case-control study of children
newly diagnosed with asthma at the university hospital in Kuopio, Finland
[15]. Cases were defined as children 1 to 7 years of age who had been referred
to the hospital because of two or more attacks of wheezing within the past
year or were newly diagnosed with asthma. Controls who did not have
asthma were randomly drawn from the Finnish population registry and
matched by age, gender, and municipality to cases. Cases and controls
were required to have lived at least 2 years or at least 75% of their lifetime
in their current homes. Participation rates and study numbers for cases and
controls were 98% (n ¼ 121) and 84% (n ¼ 241). Homes were inspected for
evidence of mold odor, visible mold, and water damage. Models adjusted
for parental asthma, paternal education, number of siblings, indoor pets,
and daycare attendance during the first year of life yielded significant results
for water damage in the main living area (OR 2.24; 95% CI, 1.25–4.01) and
visible mold in the main living area (OR 2.59; 95% CI, 1.15–5.85). The study
found a trend for increased risk for newly diagnosed asthma with each ad-
ditional square meter of observed home water damage (OR 1.36; 95% CI,
0.91–2.03).

Dampness/mold and dyspneadrecent publications

Recent studies have investigated associations with dyspnea, nocturnal
dyspnea, dyspnea during exertion, dyspnea after exertion, and dyspnea at
rest, with differing results. The findings of Gunnbjörnsdóttir and colleagues
in relation to dyspnea were discussed previously. Park and colleagues devel-
oped a grading system for visible water stains, visible mold, mold odor, and
moisture, which they applied in an investigation of 1231 employees (mean
age 51 years) of a United States community college that had several water-
damaged buildings [16]. Dampness indicators in models adjusted for age,
gender, smoking, job status, year of hire, allergies, and use of latex gloves
were shown to predict risk for dyspnea present during the past 12 months
that improved away from the building.
Others have compared the prevalence of work-related dyspnea among
employees in water-damaged and mold-contaminated buildings to a United
States survey of office workers in nonproblem buildings [10,17]. Work-
related dyspnea was defined as shortness of breath that occurred 1 or
more days per week in the past 4 weeks and which improved away from
 DAMPNESS AND MOLD IN THE INDOOR ENVIRONMENT 493

work. Although analyses could not be controlled for demographic factors,

researchers found significantly elevated prevalence rate ratios (2.2 to 4.6)
that suggested an association between building dampness and dyspnea.
Researchers in Norway studied 2819 randomly selected adults, ages 26 to
81 years, who resided 11 years earlier (time of first survey) in the same
county in Western Norway [18]. Response rate for the survey was 89%.
In logistic regression models adjusted for age, gender, smoking status,
educational level, pack years, and occupational exposure to dust or fumes,
visible mold in the home significantly increased the risks for dyspnea when
climbing two flights of stairs at an ordinary pace and of attacks of dyspnea
(OR 2.3 [95% CI, 1.35–3.85] and 1.7 [95% CI, 1.06–2.72], respectively).
In summary, all nine studies (five adult studies and four pediatric studies)
addressing environmental dampness and new-onset asthma published since
the IOM report demonstrate some significant associations between environ-
mental dampness and new-onset asthma or new-onset asthma-like symp-
toms. Additionally, all five adult studies investigating associations
between environmental dampness and dyspnea found some significant asso-
ciations between one or more measures of dyspnea and environmental
dampness. Two of these studies showed an exposure-response relationship.

Microbial exposures in damp environments and asthma

and asthma-like symptomsdrecent publications
Recent research has advanced the knowledge on associations between
asthma development or asthma-like symptoms and fungi and bacteria
(Table 3). Limitations of sampling and analytic methods for microbial
agents and lack of knowledge on which specific fungi or microbial agents
are relevant measures of risk for respiratory illness have hampered exposure
assessment. Such limitations include (1) lack of personal sampling methods
for estimating long-term exposure to airborne microbes or microbial agents,
(2) difficulty in accounting for the large temporal and spatial variability of
airborne microbial agents with standard short-term sampling methods, (3)
high sampling and analytic cost, and (4) lack of standardized analytic
methods. Despite these limitations, measured exposure assessments are
necessary to obtain evidence on possible etiologic agents of disease.

Adults
A longitudinal study of subjects who participated in the ECRHS in
Melbourne, Australia, followed 360 adults (20 to 45 years old) over
a 2-year period with regard to measured home exposures and the develop-
ment and remission of asthma [19]. The investigators measured dust mite
and cat allergens and ergosterol (the principal sterol in fungal membranes)
in bedroom floor and bed dust samples and culturable fungi from bedroom
air samples at the onset of the study and 2 years later. They found that
 494
Table 3
Epidemiologic studies investigating an association between microbial agents and asthma and asthma-like symptoms
Odds ratios
Total Specific Other Fungal
Reference Study design Health outcome fungi fungi fungi biomass Endotoxin Bacteria MVOC
Adults
Matheson [19]a Longitudinal study: Development:
home (20–45 y) Current asthma 1.5 (a) 1.0 (Cla/a) 1.1 (a) 1.1 (Erg/fd) – – –

SAHAKIAN
Asthma attack 1.5 (a) 1.5 (Cla/a) 1.2 (a) 1.0 (Erg/fd) – – –
PD asthma 0.9 (a) 1.0 (a) 1.0 (a) 1.5 (Erg/fd) – – –
Remission:
Current asthma 1.2 (a) 1.1 (Cla/a) 0.9 (a) 1.1 (Erg/bd) – – –

et al
Wheeze 1.0 (a) 1.0 (Cla/a) 1.0 (a) 0.8 (Erg/bd) – – –
BHR 1.0 (a) 1.0 (Cla/a) 0.9 (a) 0.9 (Erg/bd) – – –
Park et al [20]b Case-control study: Post-occupancy 1.6 (fd) 2.2 (Hyd/fd) 0.7 (fd) 1.4 (Erg/fd) 1.4 (fd) – –
office (mean age 46 y) PD asthma 1.7 (cd) 1.9 (Hyd/cd) 1.3 (cd) 1.6 (Erg/cd) 1.2 (cd) – –
PD asthma or 1.7 (fd) 1.8 (Hyd/fd) 1.1 (fd) 1.6 (Erg/fd) 1.5 (fd) – –
asthma symptoms 1.6 (cd) 1.6 (Hyd/cd) 1.3 (cd) 1.5 (Erg/cd) 1.1 (cd)
Park et al [21]c Cross sectional study: WR wheeze 2.0 (fd) d d d 2.5 (fd) – –
office (mean age 46 y) WR chest-tightness 1.9 (fd) d d d 2.2 (fd) – –
WR shortness 2.4 (fd) d d d 1.9 (fd) – –
of breath
WR cough 1.7 (fd) d d d 1.3 (fd) – –
c
Salo et al [22] Cross sectional study: Current PD asthma – 1.7 (Alt/sd) – – – – –
home (73% O18 y)
Children
Douwes Birth cohort study: PD asthma by age 4 d d d 0.4 (EPS/fd) 0.4 (fd) d d
et al [26]d home (1–4 y) 0.7 (Glu/fd)
Persistent wheeze d d d 0.4 (EPS/fd) 0.7 (fd) d d
in past 4 years 0.4 (Glu/fd)
Hyvärinen Case-control study: Development d 1.1 (Mes/hd) d 1.1 (Erg/hd) 0.7 (hd) 1.2 (Mes, Act/hd) d
et al [27]e home (1–7 y) of asthma 1.1 (Xer/hd) 1.0 (Mes/hd)
van Strien Cross-sectional study: PD asthma 1.1 (Mur/bd)

DAMPNESS AND MOLD IN THE INDOOR ENVIRONMENT

d d d d d d
et al [28]b home (6–14 y) Wheeze d d d d d 0.6 (Mur/bd) d
Kim et al [29]f Cross- sectional study: PD asthma 0.94 (a) d d d d 0.97 (a) 2.1 (a)
elementary school Nocturnal 0.84 (a) d d d d 0.92 (a) 5.2 (a)
breathlessness
Daytime 0.94 (a) d d d d 0.97 (a) 1.8 (a)
breathlessness
Wheeze 0.93 (a) d d d d 0.99 (a) 1.4 (a)
ORs in bold font are significant for P % 0.05. Underlined ORs are marginally significant for 0.05 ! P % 0.10.
Abbreviations: a, airborne; act, actinomycetes; Alt, Alternaria; bd, bed dust; BHR, bronchial hyper-reactivity; cd, chair dust; Cla, Cladosporium; EPS,
extracellular polysaccharide of Penicillium and Aspergillus species; Erg, ergosterol; fd, floor dust; Glu, glucan; hd, house dust; Hyd, hydrophilic; Mes,
mesophilic; mur, muramic acid; PD, physician-diagnosed; sd, surface dust; WR, work-related; Xer, xerophilic.
a
ORs are for twofold increase of exposure in the second survey compared to the first survey.
b
ORs are for IQR increase (cfu/g dust) in exposure.
c
ORs are for highest tertile compared to lowest tertile exposure group.
d
ORs are ratios are for high compared to low exposure group.
e
ORs are for each 0.01 nm/mg increase of endotoxin, 105 cfu/g increase of mesophilic bacteria, 103 cfu/g increase of mesophilic actinomycetes, 103 pg/mg
increase of ergosterol, 105 cfu/g increase of mesophilic fungi, and 105 cfu/g increase of xerophilic fungi.
f
ORs are for each 102/m3 increase of bacteria or mold and 1 mg/m3 increase of total MVOC.

495
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different content
 Law - Field Notes
Second 2023 - Laboratory

Prepared by: Assistant Prof. Davis

Date: August 12, 2025

Unit 1: Study tips and learning strategies

Learning Objective 1: Research findings and conclusions
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 2: Experimental procedures and results
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Learning Objective 3: Comparative analysis and synthesis
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Learning Objective 4: Current trends and future directions
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 4: Diagram/Chart/Graph]
Learning Objective 5: Case studies and real-world applications
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Statistical analysis and interpretation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Note: Best practices and recommendations
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Statistical analysis and interpretation
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 8: Assessment criteria and rubrics
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 9: Interdisciplinary approaches
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Quiz 2: Interdisciplinary approaches
Note: Key terms and definitions
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Ethical considerations and implications
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 12: Problem-solving strategies and techniques
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Example 13: Statistical analysis and interpretation
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Interdisciplinary approaches
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Fundamental concepts and principles
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Experimental procedures and results
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Statistical analysis and interpretation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 18: Best practices and recommendations
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 19: Study tips and learning strategies
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Conclusion 3: Best practices and recommendations
Important: Practical applications and examples
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Key Concept: Best practices and recommendations
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Learning outcomes and objectives
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 23: Diagram/Chart/Graph]
Important: Practical applications and examples
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 24: Comparative analysis and synthesis
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Experimental procedures and results
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 26: Diagram/Chart/Graph]
Remember: Assessment criteria and rubrics
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Study tips and learning strategies
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Research findings and conclusions
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
References 4: Key terms and definitions
Practice Problem 30: Statistical analysis and interpretation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Literature review and discussion
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 32: Diagram/Chart/Graph]
Important: Assessment criteria and rubrics
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Historical development and evolution
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Critical analysis and evaluation
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 35: Diagram/Chart/Graph]
Key Concept: Historical development and evolution
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
[Figure 36: Diagram/Chart/Graph]
Practice Problem 36: Interdisciplinary approaches
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Key terms and definitions
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 38: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Comparative analysis and synthesis
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice 5: Critical analysis and evaluation
Example 40: Key terms and definitions
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Experimental procedures and results
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Remember: Critical analysis and evaluation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 43: Critical analysis and evaluation
• Comparative analysis and synthesis
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Key terms and definitions
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Statistical analysis and interpretation
• Research findings and conclusions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Note: Ethical considerations and implications
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 47: Diagram/Chart/Graph]
Key Concept: Best practices and recommendations
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Practical applications and examples
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Research findings and conclusions
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice 6: Ethical considerations and implications
Note: Theoretical framework and methodology
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Interdisciplinary approaches
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 52: Diagram/Chart/Graph]
Definition: Case studies and real-world applications
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Remember: Critical analysis and evaluation
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Critical analysis and evaluation
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 55: Current trends and future directions
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Experimental procedures and results
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 57: Historical development and evolution
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Fundamental concepts and principles
• Experimental procedures and results
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Definition: Statistical analysis and interpretation
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Part 7: Critical analysis and evaluation
Note: Ethical considerations and implications
• Problem-solving strategies and techniques
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Key Concept: Fundamental concepts and principles
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Interdisciplinary approaches
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Theoretical framework and methodology
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Practice Problem 64: Case studies and real-world applications
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Practical applications and examples
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Study tips and learning strategies
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Theoretical framework and methodology
• Statistical analysis and interpretation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 68: Comparative analysis and synthesis
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Literature review and discussion
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Practice 8: Experimental procedures and results
Remember: Study tips and learning strategies
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Definition: Problem-solving strategies and techniques
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Practice Problem 72: Literature review and discussion
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 73: Diagram/Chart/Graph]
Key Concept: Key terms and definitions
• Theoretical framework and methodology
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Note: Historical development and evolution
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Important: Learning outcomes and objectives
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Practice Problem 76: Critical analysis and evaluation
• Assessment criteria and rubrics
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Study tips and learning strategies
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Remember: Comparative analysis and synthesis
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Example 79: Statistical analysis and interpretation
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Summary 9: Practical applications and examples
Key Concept: Current trends and future directions
• Literature review and discussion
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Example 81: Theoretical framework and methodology
• Key terms and definitions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Historical development and evolution
• Fundamental concepts and principles
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Theoretical framework and methodology
• Historical development and evolution
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 84: Diagram/Chart/Graph]
Practice Problem 84: Historical development and evolution
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Study tips and learning strategies
• Interdisciplinary approaches
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Important: Experimental procedures and results
• Critical analysis and evaluation
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Statistical analysis and interpretation
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Definition: Interdisciplinary approaches
• Study tips and learning strategies
- Sub-point: Additional details and explanations
- Example: Practical application scenario
Formula: [Mathematical expression or equation]
Practice Problem 89: Historical development and evolution
• Current trends and future directions
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
[Figure 90: Diagram/Chart/Graph]
Practice 10: Literature review and discussion
Practice Problem 90: Interdisciplinary approaches
• Ethical considerations and implications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Key Concept: Study tips and learning strategies
• Case studies and real-world applications
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
[Figure 92: Diagram/Chart/Graph]
Important: Ethical considerations and implications
• Learning outcomes and objectives
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Formula: [Mathematical expression or equation]
Note: Literature review and discussion
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
[Figure 94: Diagram/Chart/Graph]
Important: Current trends and future directions
• Practical applications and examples
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
Remember: Key terms and definitions
• Best practices and recommendations
- Sub-point: Additional details and explanations
- Example: Practical application scenario
- Note: Important consideration
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