CRDConcept: fungi: health effects

of the estimated estimated 50,000 to 250,000 species of fungi, fewer than 200 have been described as human pathogens that can cause infections". "Molds can cause illnesses in situations other than humid indoor environments. We have documented that molds can cause infections in susceptible people, particularly in hospital settings where 9% of hospital-acquired (nosocomial) infections are caused by fungi. Respiratory infections due to inhalation of the fungus Aspergillus have been documented mostly in immunocompromised individuals. Molds also have been associated with some cancers. Two mold-produced toxins (aflatoxins and ochratoxin A) have been classified by the National Toxicology Program as human carcinogens (http://ntp-server.niehs.nih.gov/). Chronic ingestion of these toxins from eating contaminated foods has been associated with liver and kidney tumors in animals and people. " -- Redd, S. C., 2002, State of the science on molds and human health

"There are more than a million species of fungi, but only about 400 cause diseases relevant to man, animals, or plants. " Dr. Fungi

Fungi exposures have three possible reactions from human: allergic reactions, infections and toxic responses. (Gorny, R. L., Reponen, T., Willeke, K., Schmechel, D., Robine, E., Boissier, M. and Grinshpun, S. A., 2002, Fungal fragments as indoor air biocontaminants))

The signs and symptoms are familiar to many: Sneezing often accompanied by a runny or clogged nose; Coughing and postnasal drip; Itching eyes, nose, and throat; Allergic shiners (dark circles under the eyes caused by increased blood flow near the sinuses) ; The "allergic salute" (in a child, persistent upward rubbing of the nose that causes a crease mark on the nose); Watering eyes; Conjunctivitis (an inflammation of the membrane that lines the eyelids, causing red-rimmed, swollen eyes, and crusting of the eyelids). Airborne Allergens - National Institute of Allergy and Infectious Disease's

"There is a considerable body of evidence that indoor biological agents such as mold (fungi), dust mites, and bacterial endotoxins are associated with adverse health effects, as well as the degradation of the building and its contents and unpleasant appearance and odors. Some species of fungi produce potent mycotoxins and allergens. Clinically recognized diseases caused by fungi include cancer, infection, hypersensitivity pneumonitis, and allergic bronchopilmanary aspergillosis. Apart from these clinically recognized diseases, the reported presence of visible mold in houses has been consistently associated with increased symptoms, if not objective measures, of health" (Lawton, M. D., 1998, Moldy houses - building science lessons from the wallaceburg project)

"The dose-response data for fungal agents of disease are unavailable": Common Mycotoxins and molds, Diseases Due to Environmental Moulds by Dr. Fungi, Guidelines on Assessment and Remediation of Fungi in Indoor Environments

Health effect

Health and welfare associated to the fungi have been an important concern (Health and Welfare Canada, 1987) and have been targets of much research (Miller, 1992; Dales, et al., 1991; Beneke and Rogers, 1996; de Hoog and Guarro, 1995; Kwong-Chung and Bennett, 1992; Spengler et al., 1992).

The main sources of the fungal exposure are the spores, fungal hyphae threads, fungal metabolites, and allergens in digestive enzyme. Although there have been many studies conducted to reveal the exact microbial responsible agents, no specific microbe or toxin has been identified as the dominating cause (Peltola, 2000).

The adverse effects of mold and fungi can be seen in three folds: allergy, medical complaints, and real health effects.
Allergy

Allergy is the most common symptom associated with exposure to elevated levels of fungi. Most fungi produce antigenic proteins that can cause allergic reactions in allergy sensitive individuals including conjunctivitis, rhinitis, bronchitis, asthma and hypersensitivity pneumonitis (Peart and Gatley, 1992).

Certain individuals will develop asthma and nasal symptoms if they breathe in spores and thus have a mold allergy. The higher level of spore concentration in the air the worse the reaction is likely to be. The cause of the allergy reaction is due to that some molds can produce toxins that can act as immuno suppressors.

"About 5% of individuals are predicted to have some allergic airway symptoms from molds over their lifetime." - 2561

Complaints

Mold exposure can produce a large variety of symptoms that are reported in everyday medical complaints. These include depression, irritability, anger, fear, coughing, wheezing, runny eyes and nose, muscular aches, chills, fever, headaches, confusion, inability to concentrate, tiredness, fatigue, sleep disorders, hay fever, allergy type symptoms, loss of appetite, skin rashes, hypersensitivity pneumonitis, allergic rhinitis and asthma.

Health risk

Mold can cause allergies and respiratory disease, and the toxins it produces can wear down the immune system - leaving people, especially children, vulnerable to many illnesses (CMHC, 1996). CDC (1997) has found an apparent link between mold contamination in the homes and cases of infant pulmonary hemorrhage. Mold has been linked to instances of subclinical, acute and chronic respiratory disease (Peart and Gatley, 1992).

Studies on the health effects of fungi exposure include Bernstein et al. (1983) on airborne spore in contaminated ventilation system; Horner et al. (1995) on fungal allergens; Samson and Flannigan (1994) on the IAQ aspect.

For references see: References for mold and fungi studies [J. Rao, 1999]

Guidelines on mold/fungal exposure

"Air Quality Sciences (AQS) announces the release of a landmark study on mold in homes, ˇ°Air and Dustborne Mycoflora in Houses Free of Water Damage and Fungal Growth,ˇ± ˇ in which data was collected from 50 single family homes with no history of major water damage ˇ is a critical step in understanding what is ˇ°normal and typicalˇ± so that there is a baseline against which to compare data from suspected problem homes. .." (Online source)

Fungi exposure Guideline

American Industrial Hygiene Association (AIHA): a manual of methods for microbiological sampling (Dillon et al., 1996),
American Conference of Government Industrial Hygienists (ACGIH): a paper on microbiological problems in buildings (Macher et al., 1999).,
Canadian Federal-Provincial Committee on Environmental and Occupational Health: guidelines on fungal contamination in public buildings (1995) R-1942,
Commission of the European Communities (CEC): a report on Biological Particles in indoor environments with the strategy and methodology for investigating indoor environments, including recommendations (1993),

Other info:

5-30% of atopic symptoms may be the results of prolonged exposure to allergenic spores in air. Several thousand mould species are strong allergens -- Gutarowska, B. and Zakowska, Z., 2002, Elaboration and application of mathematical model for estimation of mould contamination of some building materials based on ergosterol content determination..

A short article on Toxic Mold by J. Duncan Findlay 2002: good overview

old 101: An Overview for Safety Professionals by Wonder makers Environmental inc. 2001.

"As allergenicity is independent of viability,"

Web Links (38):

Notes

A Brief Guide to Mold, Moisture, and Your Home - EPA: "Guide provides information and guidance for homeowners and renters on how to clean up residential mold problems and how to prevent mold growth. "
AAP - AMERICAN ACADEMY OF PEDIATRICS: Web site for "American Academy of Pediatrics (AAP) and its member pediatricians dedicate their efforts and resources to the health, safety and well-being of infants, children, adolescents and young adults."
ACGIH - American Conference of Industrial Hygienists: "a member-based organization and community of professionals that advances worker health and safety through education and the development and dissemination of scientific and technical knowledge"
Achieving Healthy Indoor Environments in Canada: "cross-Canada, multi-stakeholder consultation, strategy development and alliance building process for achieving healthy indoor environments in Canada"
Aerobiology- Fungal Populations in Indoor Air by Megan Hargreaves: A nice article about fungal stuff in indoor, toxin, and health
AIHA: "promotes, protects, and enhances industrial hygienists and other occupational health, safety and environmental professionals in their efforts to improve the health and well being of workers, the community, and the environment"
Air Quality Sciences AQS: An IAQ company "To evaluate and maintain acceptable air quality in indoor spaces,...". With good background information.
Airborne Allergens - National Institute of Allergy and Infectious Disease's: an online chapter on allergens
Bioaerosols, Fungi and Mycotoxins, Ed. by Johanning, E.: "papers presented at the September, 1998 Third International Conference in Saratoga Springs, New York. clinical and epidemiological studies and technical reports on an emerging public health topic affecting people in indoor environments at work and at home."
Can Do: "aimed at industrial and institutional buildings and home air quality, including proper maintenance of furnaces and air conditioners.
David D. Palmer Health Sciences Library!: library search
Discussion forum by Toxic Mold
Dr. Fungi: Extensive collection of non-technical info on fungi, 2000+ references. Emphasis on discausing species.
fungal research group pub-abs: More than 60 references with abstract on mold, house, and health, also see the other half of the list
Health Canada: "Health Canada" site by the Government of Canada, covers aspects of health for all that lives.
Health Related Papers at Indoor Air `99 ¨C What Is New and Interesting? An Overview: "This paper summarizes important new contributions submitted among the many fine health-related papers presented at Indoor Air `99. "
HealthySchools.com: " a proactive tool to help Ontario school boards identify, prevent, and remediate indoor environment problems that could otherwise affect children's health and learning adversely"
Indoor Air Quality (IAQ) of EPA: Information about IAQ, molds, Asthma, radon, etc.
Indoor molds - PubH4103: A well organized articles on molds, transport, monitoring, exposure, control, health effects, toxicity, biomarkers, etc.
Is Indoor Mold Contamination a Threat to Health? by Harriet M. Ammann: A good article of mold, health, toxin.
Mediators of inflammation: "Home page of the journal Mediators of Inflammation which focuses on research into cytokines, biological response modifiers and the family of cell adhesion-promoting molecules. "
Medical Mycology: formerly Journal of Medical and Veterinary Mycology, a bimonthly international journal publishing original work on all aspects of invasive fungal disease in humans and animals.
mold info at Environmental Testing & Technology: "to provide an investigative and consulting service for indoor environmental problems in commercial and residential buildings"
Mold lawyer.com
Mold Resources - EPA: A great starting point for exploring.
Mold: The Whole Picture - Abbey Newsletter: A 4 series of articles on mold by Ellen McCrady: The Whole Picture Pt. 1; Pt. 2, Assessment of Mold Problems; Pt. 3, A Neglected Public Health Problem; Part 4: Effect of Mold on Schools, Homes, & Human Beings
Mycotoxin List
NIEHS -National Institute of Environmental Health Sciences: "to reduce the burden of human illness and dysfunction from environmental causes by understanding each of these elements and how they interrelate."
Ohio Toxic Mold information: web resources on toxic molds
OSH-DB Occupational Safety and Health Database: "OSH-DBTM (Occupational Safety and Health Database) is a web accessible database with over 220,000 original abstracts covering virtually all aspects of the occupational safety and health field. Records contain original abstracts as well as complete bibliographic information."
pathogenic fungi database - Institute of Medical Mycology (TIMM): The database includes list of 1631 species related to toxic fungi
Projects at Laboratory of INDOOR AIR AND Occupant Health - U of Kuopio: some collaborative projects on mold-moisture-health
School of Occupational and Environmental Hygiene - UBC: "research programs into five broad areas: Acoustics, Environmental bioaerosol exposure methods development, Exposure assessment and epidemiology, Occupational and environmental policy, Occupational and environmental respiratory disease.. ". (Research publications
Systematic Botany and Mycology databases: Searchable of fungi
themoldsource: Good source for news, articles, symptoms, testing, remedy, litigations related to molds
Toxic Mold Injury Resources: very extensive resources regarding toxic mold, mold test kits, medical, by Heindl Law Firm
WHO -- World Health Organization: "the United Nations specialized agency for health, was established on 7 April 1948. WHO's objective, as set out in its Constitution, is the attainment by all peoples of the highest possible level of health. Health is defined in WHO's Constitution as a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. WHO is governed by 192 Member States through the World Health Assembly. The Health Assembly is composed of representatives from WHO's Member States. The main tasks of the World Health Assembly are to approve the WHO programme and the budget for the following biennium and to decide major policy questions. "
wondermakers.com articles on on health and safety: articles concerning to "solve environmental, health, and safety problems."

Related References (90)

--------: A brief guide to mold, moisture, and your home, by EPA, 2002
expose to hampness and molds: Adverse health effects in adults exposed to home dampness and molds, by Dales, R. E., Burnett, R., and Zwanenburg, H., 1991
--------: Adverse health effects of indoor molds, by Curtis, L., Allan stark, M. and William vetter, M., 2004
--------: Adverse human health effects associated with molds in the indoor environment, by Hardin, B. D., Kelman, B. J. and Saxon, A., 2003
suvey of allergens, home: Allergens in the home: a review, by Short, S., 2000
--------: An epidemiological study of the relative importance of damp housing in relation to adult health, by Evans, J., Hyndman, S., Stewart-Brown, S., Smith, D. and Petersen, S., 2000
--------: An overview of the health effects due to mold exposure, An Overview of Residential Ventilation Activities in the Building America Program (Phase I), by Shum, M. and Goodman, M., 2002
--------: Anatomy of a Fungal Problem , by Carlson, N., Quraishi, A., 2001
--------: Application of biomarkers to assessment of risk to human health from exposure to mycotoxins, by Miraglia, M., Brera, C. and Colatosti, M., 1996
--------: Bioaerosols, fungi and mycotoxins: health effects, assessment, prevention and control, by Johanning, E. (Ed), 1999
--------: Building-associated pulmonary disease from exposure to Stachybotrys chartarum and Aspergillus versicolor, by Hodgson, M.J., Morey, P., Leung, W.Y., Morrow, L., Miller, D., Jarvis, B.B., Robbins, H., Halsey, J.F. and Storey, E., 1998
--------: Building-related symptoms and molds: a two-step intervention study, by Ebbehoj, N. E., Hansen, M. O., Sigsgaard, T. and Larsen, L., 2002
metabolites: Can microbial volatile metabolites cause irritation at indoor air concentrations? , by Pasanen, A., Korpi, A., Kasanen, J.P., Pasanen, P., 2001
--------: Characterizing moisture damaged buildings - environmental and biological monitoring, by Hyv?rinen, A., 2002
review: Clinical findings related to indoor fungal exposure - review of clinic data of a specialty clinic, by Johanning, E., Landsbergis, P., 2001
Cognitive Impairment: Cognitive Impairment Associated with Exposure to Toxigenic Fungi , by Gordon, W. A., Johanning, C., Haddad, L., 2001
--------: Comparison of two-level and three-level classifications of moisture-damaged dwellings in relation to health effects , by Haverinen, U., Husman, T., Vahteristo, M., Koskinen, O., Moschandreas, D., Nevalainen, A. and Pekkanen, J., 2001
--------: Critical aspects on the significance of microbial volatile metabolites as indoor air pollutants , by Pasanen, A., Korpia, A., Kasanena, J. and Pasanena, P., 1998
--------: Diagnosing the cause of a "sick building:" a case study of an epidemiological and microbiological investigation, by Craner, J., Linda, M. P. H., Stetzenbach, D., 2001
inflammatory: Effect of growth medium on potential of Streptomyces anulatus spores to induce inflammatory responses and cytotoxicity in RAW264.7 macrophages, by Hirvonen, M., Suutari, M., Ruotsalainen, M., Lignell, U. and Nevalainen, A., 2001
--------: Effects after mold exposure -- which are the causative agents?, by Rylander, R., 2001
--------: Effects of damp and mould in the home on respiratory health: a review of the literature, by Peat, J. K., Dickerson, J. and Li, J., 1998
--------: Evaluation of the genotoxic potential of some microbial volatile organic compounds (MVOC) with the comet assay, the micronucleus assay and the HPRT gene mutation assay , by Kreja, L. and Seidel, H., 2002
--------: Exposure measures for studies of mold and dampness and respiratory health , by Miller, J. D., Dales, R., White, I., 1999
exposure to MVOC: Exposure to airborne fungi, MVOC and mycotoxins in biowaste-handling facilities, by Fischer, G., M¨ąller, T., Schwalbe, R., Ostrowski, R. and Dott, W., 2000
exposure fo respriable molds: Exposures to respirable, airborne penicillium from a contaminated ventilation system: Clinical, environmental epidemiological aspects, by Bernstein, R. S., W. G. Sorenson, D. Garabrant, and R. D. Treitman, 1983
--------: Fungal allergies , by Nolard, N., 2001
a good review: Fungal contamination in public buildings: a guide to recognition and management, by Davies, R., Summerbell, R. C., Haldane, D., Dufour, A., Yu, K., Broder, I., Dales, R., Kirkbride, J., Kauri, T. and Robertson, W., 1995
--------: Fungal growth in buildings: the aerobiological perspective , by Burge, H. A., 2001
--------: Fungal growth in buildings: the aerobiological perspective , by Burge, H. A., 2001
respiratory: Fungal spores as such do not cause nasal inflammation in mold exposure, by Reponen, M., Seuri, M., Nevalainen, A. and M.-R. Hirvonen, 2002
--------: Health effects of indoor-air microorganisms, by Husman, T., 1996
in public schools: Health effects of mold exposure in public schools, by Santilli, J., 2002
--------: Health Effects of Moulds (Molds): State of Knowledge, by Connell, C. P., 0
toxin of molds: Health effects of toxin-producing indoor molds in California, by California Department of Health Services, 1998
a book: Health implications of fungi in indoor environments, by Samson, R. and B. Flannigan, 1994
--------: Health risk assessment of fungi in home environments, by Verhoeff, A. P. and Burge, H. A., 1997
--------: Health risks associated with the indoor presence of moulds, by INSPQ, 2002
--------: Housing characteristics, reported mold exposure, and asthma in the european community respiratory health survey, by Zock, J.P., Jarvis, D., Luczynska, C., Sunyer, J. and Burney, P., 2002
--------: IAQ and human toxicosis: empirical evidence and theory, by Ammann, H. M., 2001
school: Improved health after intervention in a school with moisture problems, by Ahman, M., Lundin, A., Musabasic, V., Soderman, E., 2000
school: Increased prevalence of atopy among children exposed to mold in a school building, by Savilahti, R., J. Uitti, et al., 2001
--------: Indoor air microbes and respiratory symptoms of children in moisture damaged and reference schools , by Meklin, T., Husman, T., Veps?l?inen, A., Vahteristo, M., Koivisto, J., Halla-aho, J., Hyv?rinen, A., Moschandreas, D. and Nevalainen, A., 2002
--------: Indoor air quality and health does fungal contamination play a significant role?, by Bardana, E. J., 2003
--------: Indoor air quality, fungi, and health - How do we stand?, by King N. and Auger, P., 2002
--------: Indoor exposure to molds and allergic sensitization, by Jacob, B., Ritz, B., Gehring, U., Koch, A., Bischof, W., Wichmann, H.E. and Heinrich, J., 2002
allergic or toxic reactions: Indoor mold growth: health hazards and remediation, by Kowalski, W. J., 2000
--------: Indoor mold, toxigenic fungi, and Stachybotrys chartarum: infectious disease perspective, by Kuhn, D. M. and Ghannoum, M. A., 2003
--------: Inflammatory and cytotoxic responses in mouse lungs exposed to purified toxins from building isolated Penicillium brevicompactum , by Mahooti-brooks, N., Storey, E., Yang, C., Simcox, N. J., Turner, W., Hodgson, M., 2004
Penicillium of indoor air: Inflammatory potential of the spores of Penicillium spinulosum isolated from indoor air of a moisture-damaged building in mouse lungs , by Jussila, J., Komulainena, H., Kosma, V., Pelkonen, J. and Hirvonen, M., 2002
respiratory diseases.: Inhalation hazards of fungal spoilage, by Lacey, J., 1993
--------: Investigations of the relationship between disease and airborne (1 -> 3)-beta-D-glucan in buildings, by Rylander, R., 1997
--------: Is indoor mold contamination a threat to health?, by Ammann, H. M., 0
--------: Lawsuits grow as moulds multiply: Homeowners are seeking damages in Canada and the U.S. as moulds bring host of health problems , by Mucalov, J. and G. Mucalov abstract:, Mucalov, J. and Mucalov, G., Mucalov, J. and Mucalov, G., 2002
--------: Lung function and symptoms in damp and mouldy buildings, by Ebbeh?j, N., Svensson, H. W. M., Valbj?rn, O. and the DAMIB-group, 2002
--------: Microfungal contamination of damp buildings - examples of risk constructions and risk materials, by Gravesen, S., Nielsen, P.A., Iversen, R., Nielsen, K.F, 1999
--------: Microfungal contamination of damp buildings: Biological aspects , by Gravesen, S., 2001
--------: Modeling moisture damage and its association with occupant health symptoms, by Haverinen, U. et al, 2001
--------: Moisture observations and health , by Mikko, V., Jouni, R., Tuula, H., Aino, N., 2001
--------: Moisture, mold and health in apartment homes , by Nevalainen, A., Vahteristo, M., Koivisto, J., Meklin, T., Hyv?rinen, A., Keski-karhu, J., Husman, T., 2001
organisms due to moisture: Moisture, organisms, and health effects, by Burge, H. A., H. J. Su, and J. D. Spengler, 1994
respiratory: Mold associated respiratory illness, by Fung, F., 2002
school: Mold growth and IAQ woes at three-year-old school spark lawsuits by school district, students, and staff in Texas towns, by Anon, 2000
--------: Mold growth linked to airtight building designs, by Christen, K., 2002
--------: Mold remediation in schools and commercial buildings, by EPA, 2001
--------: Moldy houses - building science lessons from the Wallaceburg project, by Lawton, M. D., 1998
--------: Moulds and health - an epidemiological study, by Meyer, H. W., W¨ąrtz, H., Valbj?rn, O., Sigsgaard, T., Gyntelberg, F. and the DAMIB-group, 2002
possibility: Mycological monitoring of different workplaces in Lithuania , by Lugauskas, A., Krik?taponis, A. and Bridiuvien, D., 2000
--------: Mycotoxins in crude building materials from water-damaged buildings, by Tuomi, T., Reijula, K., Johnsson, T., Hemminki, K., Hintikka, E.L., Lindroos, O., Kalso, S., Koukila-Kahkola, P., 2000
mmune response to fungal antigens: Pilot analysis of the immune response to fungal antigens in subjects working in humidity damaged houses , by Tiilikainen, A. S., Heikkinen, I., Venp??, K., Karttunen, R., 2001
good summary and references: Prediction of toxigenic fungal growth in buildings by using a novel modelling system, by Rowan, N.J., Johnstone, C.M., McLean, R.C., Anderson, J.G. and Clarke, J.A., 1999
respiratory: Prevalence and residential determinants of fungi within homes in Melbourne, Australia, by Dharmage, S., Bailey, M., Raven, J., Mitakakis, T., Thien, F., Forbes, A., Guest, D., Abramson, M. and Walters, E.H, 1999
--------: Quantification of health effects of combined exposures: a new beginning, by Miller, J. D., 1995
--------: Residential fungal contamination and health: Microbial cohabitants as covariates, by Dales, R.E., Miller, D., 1999
--------: Respiratory recommendations from EPA's mold remediation guidelines , by Anon, 2003
--------: Review of concentration standards and guidelines for fungi in indoor air, by Rao, C., Burge, H. and Chang, J., 1996
--------: Sensory irritating potency of some microbial volatile organic compounds (MVOCs) and a mixture of five MVOCs, by Korpi, A., Kasanen, J.-P, Alarie, Y., Kosma, V. and Pasanen, A-L, 1999
Sensory irritation: Sensory irritation of microbially produced volatile organic compounds in mice during repeated exposures , by Korpi, A., Pasanen, J., Pasanen, A., 2001
--------: Skin-prick test findings in students from moisture- and mould-damaged schools: A 3-year follow-up study , by Immonen, J., Meklin, T., Taskinen, T., Nevalainen, A. and Korppi, M., 2001
Stachybotrys chartarum, comprehensive review: Stachybotrys chartarum: Current Knowledge of Its Role in Disease, by Sudakin, D. L., 2000
--------: State of the science on molds and human health, by Redd, S. C., 2002
relative toxigenic potential of mycotoxins: Studies of sick building syndrome. IV. Mycotoxicosis, by Assouline-Dayan, Y., Leong, A., Shoenfeld, Y. and Gershwin, M.E, 2002
--------: Symptoms associated to work in a water damaged school building, by Sigsgaard, T., Jensen, H. L. C., Nichum, E., Gravesen, S., Larsen, L., Hansen, M. ?., 2001
--------: The European community respiratory health survey: what are the main results so far?, by Janson, C., Anto, J., Burney, P., Chinn, S., de Marco, R., Heinrich, J., Jarvis, D., Kuenzli, N., Leynaert, B., Luczynska, C., 2001
--------: The relationship between moisture or mould observations in houses and the state of health of their occupants, by Koskinen, O.M., Husman, T.M., Meklin, T.M. and Nevalainen, A.I, 1999
toxic aspect of molds: Toxic effects of indoor molds, by Committee on Environmental Health, 1998
--------: Toxic Effects of Indoor Molds (RE9736), by American Academy of Pediatrics, 1998
restoration industry: Understanding mold in the property restoration industry, by Servpro Industries, Inc, 2001
--------: Worldwide exposure standards for mold and bacteria, 5th Ed., by Brandys, C., Brandys, G. M., 2005
--------: Worldwide variation in prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema: ISAAC, by Beasley, R., Keil, U., vonMutius., E., Pearce, N. and et al., 1998

CRDBER, at CBS, BCEE, ENCS, Concordia, June 2014