Inquiry Into Biotoxin-Related Illnesses in Australia Submission 33

COVERING LETTER

RE: Inquiry into Biotoxin-related Illnesses in Australia, 1st August 2018

Thank you for the opportunity to make a submission to this inquiry.

About

Biological Health Services is one of Australia’s leading environmental consultancies and laboratories and provides on-site water damage assessment and mould inspections. We also process samples sent in to us from remediation contractors, assessors, occupational hygienists, tenants and homeowner occupants and from patients under medical or allied health-care from across Australia.

I write to you on behalf of Biological Health Services and by way of background will explain who I am. My name is Dr. Cameron Jones and I’m an environmental microbiologist. I have worked in the area of fungal biology (mycology) since 1991 at University as a PhD level academic researcher and lecturer in microbiology and environmental health respectively. More recently, and for close to a decade I have run Biological Health Services which is a commercial indoor air quality and microbiology lab and consultancy and am an active contributor at scientific conferences. I am also an Adjunct Research Fellow at the National Institute of Integrative Medicine and am regularly called upon as an expert witness in mould and water damage disputes. On this basis, I am pleased to make this submission to the Inquiry into Biotoxin-related Illnesses in Australia.

Introduction

In order to highlight what is common to so many of the disputes surrounding biotoxin- related illness I will recap on how I first became involved in this area. In 2005 I was engaged to perform my first paid indoor air quality and mould inspection for a couple who wanted their home tested. The husband claimed his wife could no longer live inside and was suffering from a range of allergic and auto-immune illnesses which they claimed were a result of unwanted exposure to water damage that was affecting their apartment. The couple had recently arrived from overseas in good health and had purchased a new apartment in the Southbank precinct. On entry to their home there was an immediate strong smell of mould all down the central corridor and extending into the master bedroom and open plan main living areas. Sampling indoors quickly revealed the airspace to be contaminated with high levels of airborne mould. The reason for this was an ongoing leak from the bathroom in the adjoining apartment that was causing water damage to their plasterboard party-wall, skirting and carpet. A dispute between the new owners, their neighbor and the Body Corporate was concurrent with the fear surrounding new and rapid-onset adverse health and property- damage, mould and building-defect claims and the need for successful resolution.

This started what has turned into several thousand indoor air quality and mould inspections that I have personally conducted in Victoria, interstate and overseas in residential, commercial and government buildings.

Response to the Terms of Reference

This submission focusses on many of the Terms of Reference covered by this Inquiry and is supportive of the health and safety issues and broader public health implications.

In order to do this, I have prepared a position paper that defines those aspects of water damage and mould biology that can occur within the built environment and I discuss how this is currently approached and managed by different stakeholders. For example, a search of the literature shows an increasing number of publications across different disciplines that focus on water damage, mould and health. However, there is a failure in consensus over many of these facts which can result in overestimating or underestimating the scale of the problem or its management and underpins the fundamental need for this Inquiry. It is my opinion that mould is both an environmental toxin and a threat to property. These are twin aspects of a connected-problem and at present, is not being adequately managed or solved in Australia by Government or various industry or health stakeholders. Because of this lack of consensus over what constitutes normal mould levels versus unhygienic or unsafe mould levels, there is considerable civil dispute over cause and effect and what defines exposure and risk to persons.

At the outset it is important to recognize that adverse health claims resulting from water damage are not restricted to biotoxins or in all cases result in chronic inflammation. The challenge for the Inquiry will be to highlight and extend on established scientific facts whilst providing improvements in identification of building-specific factors and linking these with sound medical diagnostics and treatments. This should result in more favorable outcomes both in the clinic and at the home-intervention and property level.

My position paper is broken up into 12 sections and addresses the Terms of Reference following the designated numbering scheme:

1. The prevalence and geographic distribution of biotoxin-related illnesses in Australia, particularly related to water-damaged buildings; 2. The prevalence of Chronic Inflammatory Response Syndrome (CIRS) or biotoxin related illness in Australian patients and the treatment available to them; 3. The current medical process of identifying biotoxin-related illness in patients and the medical evaluation of symptom complexes attributed to biotoxins and CIRS; 4. Any intersection with other chronic diseases;

2 5. Investment in contemporary Australian research to discover and provide evidence of CIRS as a chronic, multisystem disease; 6. Research into biotoxin-related illness caused from water damaged buildings; and 7. Any related matters.

How the position paper maps back to the Terms of Reference are listed in bold inside square brackets for each Section heading:

1. Introduction [1] 2. What’s in the air? [2] 3. Legal disputes – the Victorian example [1] 4. Whistleblowing, consumer and insurance fraud [3,7] 5. Where is the water? [1,4] 6. What are the symptoms? [3,5] 7. How and what do we measure? [2,4] 8. CIRS – is it just a controversial illness category? [2,6] 9. Unregulated testing methods [2,4,6] 10. Internet-era medical misinformation [2,6] 11. Improved terminology for healthcare providers [3,6] 12. Advocacy and health equity [5,6]

Recommendations

In the position paper following this letter (the submission) I will elaborate on these themes but my recommendations to the Inquiry are summarized into 6 key areas:

1. Research

Establish a fund for Australian research into indoor air quality and mould exposure following water damage or suspect water damage that investigates different building exposure metrics with the aim of cross-correlation with clinical biomarkers (e.g. questionnaires, mycotoxin, allergy, genetic screening, etc.) of exposure. This should enable and foster fundamental, collaborative, multidisciplinary and applied research. Linkage grants and direct financial support with Industry and the University and/or Clinical sectors should be encouraged.

2. Education & Training

3 educational topics and perspectives. Private RTO’s currently offer non- accredited courses thereby leading to peer-driven consensus bias for the Industry as a whole. Establish online resources and other non-accredited training through incentives for partnership development with industry groups so information verticals can be linked with for example, the Continuing Professional Development system, to foster learning and engagement.

3. Real Estate

A working party should be setup to consult and focus on tenancy and owner- occupancy issues surrounding water damage and mould hygiene with the view towards development of checklists, assessment protocols, advice and advocacy options for all stakeholders. This should include representation spanning residential, commercial real estate, investment and property management, strata, social housing, disability and aged care along with mortgage lending/banking, insurance, remediation contractors, builders, individual trades and architects, HVAC specialists, medical/healthcare/scientific, legal and dispute resolution personnel.

4. Communications

Improve the terminology and definitions surrounding exposure of persons to water damaged buildings that does not only focus on one aspect of risk (i.e. inflammation) but encompasses all aspects of adverse health linked to indoor moisture including well-established factors like allergy and respiratory distress. At present, the use of ‘CIRS’ is limiting in scope of the problem and is furthermore not accepted by the wider academic or medical community and is seen by some as a fringe-area of medicine. How the definitions, goals and recommendations that develop from this Inquiry are communicated is of the utmost importance. To appropriately message often complex scientific and medical concepts will require development of a suitable communications framework. To this end a working group with expertise in the analysis, research, development and implementation of topic-appropriate communications should be established to ensure that key messages are inclusive and accurate and do not evoke unwanted emotional attachment to marginal group-think.

5. Technical Standards & Guidelines

Minimum testing standards and guidelines for the inspection and assessment and remediation of suspect water damaged or mould contaminated buildings need to be collated and defined. These should be based on existing and established indoor air quality testing methods that provide evidence-based whole-of-home results to guide both occupants and clinicians in terms of

4 managing risk. Priority should be given to quantitative over qualitative metrics that allow for statistical significance testing.

6. Mould Related Health and Water Damage Advocacy

Public health information should be independent of internet-era medical misinformation or fake news and spin. Consumer mould-related information should reflect consensus scientific opinion whilst admitting reasoned choice of perspective. To this end support for the development of different advocacy platforms that are not based on social networks and encourage equity need to be encouraged. These could take the form of public-private partnerships, dot org community focused not for profits, online legal support, mediation and referral services through to whistleblower protections and risk assessment claims validation. Such platforms should be designed to scale and be interoperable into legislation, guidelines or codes of conduct and exploit emerging web 3.0 opportunities and decentralized and smart-data integrations.

Conclusion

Thank you once again for the opportunity to contribute to the Inquiry into Biotoxin- related Illnesses in Australia. I urge the Inquiry to consult and make recommendations across these 6 key areas raised in my position paper that support different aspects of each of the Terms of Reference.

I would welcome the opportunity to further discuss the contents of this submission.

Yours sincerely,

Dr. Cameron L. Jones, PhD.

Biological Health Services [email protected]

Adjunct Research Fellow National Institute of Integrative Medicine Telephone: 1300 13 23 50

5 TABLE OF CONTENTS

Pages

Covering Letter 1-5

Summary 6

Submission Paper 7-29

SUMMARY OF SUBMISSION

This submission begins with a covering letter outlining the basis on which I am qualified to make a submission and details my academic and business focus. I also explain how I have responded to each of the Terms of Reference and how the position paper I have authored maps back into the Inquiry. The position paper is split into 12 sections and covers different aspects of water damage, mould and biotoxin-illness in Australia. Special attention is made to discuss those aspects of practical mould inspection and how different stakeholders have different requirements depending on perspective and liability or the ‘need to treat’ the patient. It is seen that mould is one aspect of environmental medicine and aligned with more broad issues of indoor air quality and allergy response to toxins. In turn, the built environment and what happens indoors is fundamentally related to water and moisture damage which are mainly due to climate driven events, building defects or dilapidation. Attention is given to typical symptoms experienced by those living or working in damp or water damaged buildings along with a review of the established, Standards- based indoor air quality and mould testing methods. Controversial illness categories and nomenclature are reviewed against the literature and opportunities for clarification through this Inquiry are proposed. The role of advocacy and the provision of improved industry codes are discussed with the view towards how enforcement and compliance can lead to better health outcomes. This approach would also reduce unwanted issues like insurance fraud and the spread of medical misinformation whilst maximizing health equity. The position paper concludes with 6 key recommendations covering: research, education and training, real estate, communications, technical standards and guidelines and mould related health and water damage advocacy.

Date: 01/08/2018

6 SUBMISSION PAPER

1. Introduction

There is strong evidence that air pollution from environmental sources can compromise human health across all age groups1 and is responsible for one in nine deaths annually2. In turn much attention in the research literature is now focusing on indoor sources of pollution and how building factors and conditions shape microbial communities which are often referred to as the microbiome3. The literature shows that indoor dampness affects between 10-50% of the built environment depending on the type of house and various climate conditions4. A widely cited metric5 is that humans spend up to 90% of our time indoors. Therefore, the indoor microbiome environment is logically going to impact on humans to a greater or lesser extent. Australian research6 from 2012 that focused on strata housing showed that water leaks were the most common building defect with 42% experiencing indoor water leaks while another 25% suffered because of roofing defects. The scale of the problem in Australia and overseas is enormous and overlaps several disciplines and affects multiple stakeholders.

Fungi are the third most common taxonomic group by weight7 after plants and bacteria and there are between 2.2 and 3.8 million different species8. Mould is the common term for fungi and fungal growth is completely dependent on access to nutrients, available moisture, the right pH and temperature and oxygen in the air. They reproduce both sexually and asexually and a germinating spore grows by first putting out a hyphal bud which extends from the tip and repeatedly branches in a radial pattern giving rise to a colony which is composed of a network of filaments termed the mycelium. Spores will germinate whenever growth conditions are favorable and can be spread long distances on air currents.

Moulds are normal, both indoors and outdoors and should not be viewed as always pathogenic. When porous building materials become damp9, there is selection pressure

1 Holgate ST. Every breath we take: The lifelong impact of air pollution’ - A call for action. Clin Med J R Coll Physicians London 2017;17(1):8-12. 2 World Health Organization. Ambient Air Pollution: A global assessment of exposure and burden of disease. World Heal Organ 2016;1–131. 3 Adams RI, Bateman AC, Bik HM, et al. Microbiota of the indoor environment: a meta-analysis. Microbiome 2015;3:49. 4 WHO. WHO guidelines for indoor air quality: dampness and mould. 2009. 5 Bone A, Murray V, Myers I, et al. Will drivers for home energy-efficiency harm occupant health? Perspect Public Health 2010;130:233–238. 6 Easthope H, Randolph B, Judd S. Governing the compact city. City Future Research Centre, Faculty of the Built Environment, UNSW 2012. 7 Bar-On YM, Phillips R, Milo R. The biomass distribution on Earth. Proc Natl Acad Sci 2018; 201711842. 8 Hawksworth DL, Lucking R. Fungal diversity revisited: 2.2 to 3.8 million species. Microbiology Spectrum 2017;5(4):FUNK-0052-2016. 9 Mendell, M.J., Macher, J.M. and Kumagai, K. (2018). Measured moisture in buildings and adverse health effects: A review. Indoor Air. 28(4): 488-499.

7 and the local microflora can quickly grow out of control and lead to adverse health effects like asthma. The association between confirmed moisture damage and overgrowth of various fungi, bacteria and yeasts and their connection with many aspects of adverse public health are increasingly appearing in the literature.

The health effects from exposure to mould comes about through a reaction to (i) volatiles liberated from fungal growth, (ii) mycotoxins in the spores and (iii) respiratory illness or distress caused by inhalation of spores or cell wall fragments and via (iv) direct and indirect infection transmission.

2. What’s in the air?

The study of biological cells and particles in the air outdoors and indoors is commonly referred to as aerobiology and dates back to the 1930’s. Air borne particles may include pollen, plant and fungal spores as well as bacteria, virus and cell fragments of biological origin. This discipline has always been about the relationship between microorganisms present in the air and their potential for causing disease and dates back to the early germ theories of Louis Pasteur (1822-95) and later Robert Koch (1876-) and then many others who all sought to investigate the “ancient belief that wind brings disease”10. This has led to the recent, more modern approach which considers the microbiology of the built environment by looking at how we share our personal and built environments with the microbes11 and indoor air quality that focuses on airborne spread of potential pathogens12.

The principal vector enabling contact between water damage microorganisms and people is of course direct inhalation from the air or skin contact with affected surfaces or with settled spores. This is the foundation principle of infection. However, it should be recognized that not all contact between persons and fungi will result in infection. The issue of immune status and susceptibility is therefore of some strong significance with regard to water damage assessment and predicting the probability of adverse health for any person or group.

What then does the literature reveal for popular key work searches of relevance to this Inquiry? A scan of the US National Library of Medicine, National Institute of Health PubMed database reveals that the common terms:

• indoor air quality, • mould illness,

10 Lacey, M.E. and West, J.S. (2006). The Air Spora – A Manual for catching and identifying airborne biological particles. Springer. The Netherlands. 11 Bennett, J.W., Olsiewski, P., Raskin, L. and Marsh, A.S. (2015). American Society for Microbiology. Microbiology of Built Environments. 12 Sattar, S.A. (2016). Indoor air as a vehicle for human pathogens: Introduction, objectives, and expectation of outcome. American Journal of Infection Control. 44: S95-S101.

8 • mould allergy, and • water damage and mould all show exponential or quadratic positive trends, meaning that research output is growing year on year. This confirms that many academics and clinicians across disciplines and worldwide are contributing much important information linking these practical issues with unwanted health impacts. Figures 1-4 show these individual trends per topic term.

Figure 1. Number of published papers by year appearing in the PubMed database on the topic of “indoor air quality”. A quadratic trend line of best fit shows the popularity of this research area.

Figure 2. Number of published papers by year appearing in the PubMed database on the topic of “mould illness”. An exponential trend line of best fit shows the popularity of this research area.

Figure 3. Number of published papers by year appearing in the PubMed database on the topic of “mould allergy”. A quadratic trend line of best fit shows the popularity of this research area.

Figure 4. Number of published papers by year appearing in the PubMed database on the topic of “water damage + mould”. An exponential trend line of best fit shows the popularity of this research area.

3. Legal disputes – the Victorian example

If the research output on mould, illness, allergy and health is increasing year by year, what about the number of legal cases in dispute? To this end I have examined the AustLii database13 for the number of VCAT cases in Victoria where there has been a published determination between 1998 and 2018 (up to June). The results show that there has been an increasing number of legal disputes about mould and water damage showing an increasing trend that can be plotted as an exponential. This means that there is strong likelihood for many more mould and water damage disputes to occur over the coming years (Figure 5).

13 Victorian Civil and Administrative Tribunal. https://www.austlii.edu.au/cgi-bin/viewdb/au/cases/vic/VC

Figure 5. Number of civil claims that involved mould and water damage published on the Austlii website and heard at the Victorian Civil and Administrative Tribunal between 1998-2018. The line of best fit is an exponential and it should be noted that the data point for 2018 only contains data for ½ the year to date.

Figure 5 therefore provides salient information regarding the prevalence of mould-related issues.

For this almost 20-year period, the distribution shows that 50% of the cases involved residential tenancy while 31% were building related matters; 6% retail tenancy and 13% were civil claims under planning or appeal. This is important information that also informs the weighting of influence for any new social or economic policies that could address mould and population health. In summary, this data reveals that more buildings used for residential tenancy have mould and water damage problems.

4. Whistleblowing, consumer and insurance fraud

There are also other legal issues in the areas of consumer and insurance fraud that occur nationwide surrounding water damage and mould. For example, fraud can occur in insurance markets where policyholders poses an informational advantage enabling them to report losses that did not happen14. If the information provided to or by insurance assessors or assessors tasked with mould inspection contains errors, bias or is deficient in accurately reporting on existing water damage or misses obvious foreseeable impacts of water damage like hidden mould, then such information passed onto the insurer become noisy. There would be value in reducing fraudulent claims by establishing testing standards for mould exposure which would in effect add an

14 Schiller, J. (2003). The impact of insurance fraud detection systems. Schiller, Jörg, The Impact of Insurance Fraud Detection Systems (October 1, 2003). U of Hamburg, Risk and Insurance Working Paper No. 8.

12 automatic audit layer into the claim from the outset. Floods and water related claims are also known to attract contractor fraud where one party pays a second for work that is never completed, or work expectations are underdelivered or where overcharging is a factor15. Overall, there is a need to be able to red flag suspicious claims with often erroneous fundamentals.

Fraud detection and insurance regulation is nevertheless important for general environmental sustainability and building management. Facility management needs to be mindful of reports of mould contamination and there should be fair and transparent procedures to be able to proficiently deduce the likely causes and suggest solutions that are in line with established hygiene thresholds16.

Public accountability is a fundamental component of whistleblowing and is considered by some as a moral responsibility17. Changing the culture surrounding accurate assessment and reporting of real (or imagined) mould exposure would encourage ethical debate and minimize the victimhood culture that has emerged around toxic black mould.

In cases of occupational workplace exposure to mould and water damage there also needs to be improved access to practical environmental health and Work Safe response, and mechanisms in place for whistleblowers and whistleblower protections18. The reason for this is that whistleblowing has the potential to alert and stop detrimental activities that could harm others19 and reduce coverups and concealment of risk. Raising concern is different to making a complaint and with mould this is often the flashpoint. It has been said that the standard you walk past is the standard you accept. Reporting a concern means you are worried about an issue, wrongdoing or risk that affects you or others20.

Three examples highlight these risks. In the first example, whistleblowing is especially important for the building and construction industry where serious water damage to homes can occur during construction that then becomes sealed into the building and hidden once new plasterboard is installed. The second example is imported goods

15 Davila, M., Marquart, J.W. and Mullings, J.L. (2005). Beyond mother nature: contractor fraud in the wake of natural disasters. Deviant Behavior. 26(3): 271-293. 16 Wu, H., Ng, T.W., Wong, J.WC. and Lai, K.M. (2018). Environmental sustainability and mould hygiene in buildings. International Journal of Environmental Research and Public Health. 15: 681. 17 Rodulson, V., Marshall, R. and Bleakley, A. (2015). Whistleblowing in medicine and in Homer’s Illiad. Med Humanit 0: 1-7. 18 John, T. (2005). Whistleblowing in Australia – transparency, accountability…but above all, the truth. Parliamentary Library Research Note. 19 Bjorkelo, B. And Matthiesen, S.B. (2011). Preventing and dealing with retaliation against whistleblowers. Vandekerckhove, Wim and Lewis, David, Whistleblowing and Democratic Values. W. Vanderckhove & D. Lewis, eds., International Whistleblowing Research Network, 2011. 20 McCutcheon, K. (2014). The standard you walk past is the standard you accept. Association for Perioperative Practice. Afpp.org.uk.

13 where mould damage to timber pallets or unusual condensation problems especially during sea-transit can affect consignment integrity. Despite potential for an insurance claim, worker safety may not always be maintained during goods handling. The third example concerns temporary and portable housing where mould may become a risk due to not being fit for purpose or prone to mould due to specific climate factors21. The fourth example concerns the widespread remediator-driven belief that once mould has been identified in the home, then items of personal property need to be decontaminated or disposed of or replaced with new. Suspension of biological plausibility means that fear of contagion takes over and even in the absence of any known direct water damage to clothing or personal contents, the potential for “settled spores” means that inflated claims for compensation or for complex cleaning can arise when domestic grade washing may be all that is required. For the insurer, this spreads the risks from building specific issues to non-specific and arguably looser claims that may require financial resolution even though infection transmission from inanimate objects is variable and reasonably well defined22.

5. Where is the water?

Mould overgrowth indoors won’t occur without excess water. This can come from climate factors, plumbing leaks or building defects that allow moisture accumulation or retention indoors. In Australia the latest research23 shows that extreme wet weather events including intense rainfall storms, flash flooding and urban flooding are expected to increase which will impact on infrastructure.

In each case the inciting incident for any mould and water damage inspection is usually one or more of the following conditions or claims and is based on a review of inspection results for over 2000 properties:

• visual evidence of mould • smell of mould • suspicion of previous water damage • known evidence of previous water damage • active or periodic water damage • dilapidation of building elements allowing rainwater or condensation to enter or accumulate • lack of thermal insulation

21 Taylor, M. (2018). Mould levels seen at Nauru detention centre are enough to cause serious health problems. The Conversation. https://theconversation.com/mould-levels-seen-at-nauru-detention-centre-are-enough-to- cause-serious-health-problems-92429 22 Bloomfield, S., Exner, M., Signorelli, C., Nath, K. and Scott, E.A. (2011). The infection risks associated with clothing and household linens in home and everyday life settings, and the role of laundry. International Scientific Forum on Home Hygiene, www.ifh-homehygiene.org. 23 Guerreiro, S.B., Fowler, H.J., Barbero, R., Westra, S., Lenderink, G., Blenkinsop, S., Lewis, E. and Li, X-F. (2018). Detection of continental-scale intensification of hourly rainfall extremes. Nature Climate Change. July 30. doi.org/10.1038/s41558-018-0245-3

14 • defective building works • inadequate heating • window fenestration (e.g. window glass thickness too thin leading to unavoidable condensation issues) • redundant or leaking HVAC plant and equipment or otherwise having compromised operation through clogged filters • inadequate crossflow ventilation (within apartments or at subfloor level in other dwellings) • inadequate venting of laundry washing or drying into common areas or into wall or roof voids (of apartments and in other newly constructed dwellings) • inadequate fresh air intake into apartments and in other newly constructed dwellings • subfloor ducting not elevated from ground leading to condensation effects • inadequate site drainage or lack of engineering pumps or suitably installed agricultural drainage resulting in condensation effects or slab heave impacting on subfloor timbers and building cracking • incorrect use or installation or failure to use sisalation (building membranes) or sarcking (wall wrap) • roofing leaks especially in tiled roofs • defective roofing works or repairs or careless penetrations made for example during solar panel installations • introduction of new insulation over old insulation without cleanup of existing hazardous particulate matter present in ageing roof voids • aged and worn carpets • lack of suitable mechanical extraction ventilation in bathrooms especially in rental accommodation and newly constructed buildings • intrinsic building defects introduced during construction such as inadequate box guttering, etc. • inadequate site supervision during construction of new buildings resulting in excessive delays between frame and truss construction and roofing works leading to long- term water damage from rainfall causing mould, water damage, and biofilm formation to damage timber framing causing whole of home mould problems during new building construction which in many cases is simply concealed behind new plasterboard walls. • concealment of known problems such as painting-over, new carpets on cracked foundation flooring to cover up slab defects or water ingress points especially in rental accommodation and new building construction. • divergence of opinion between the ingoing condition report and occupant ability to maintain property in a hygienic state • adverse indoor air quality and mould claims made against builder or trade under defect warranty period • adverse indoor air quality and mould claims made against Insurer under policy or following defective make-safe, repair or remediation works • mould resulting from retention of tarps or reliance on initial make-safe works as part of for example, emergency service repair

15 • mould resulting from water events associated with fire mitigation

The above list is typical of the real-life context that consumers have when water damage is suspected or becomes apparent. Broadly this reduces to:

1. Visible evidence of staining due to water ingress or accumulation followed by 2. The distinctive smell caused by microbial growth and decay of building materials, followed by 3. Fear of contagion or illness or causal symptom claims

For some groups like those in residential tenancy, social housing or aged care, information may not be available about possible water damage or the repair history to the building. The need to make a connection between water damage to the building and mould growth must remain the fundamental focus of all indoor air quality and mould assessments. These investigations therefore need to carefully document the exposure history of the occupants and provide an evidence-based report that clearly links each indoor room or location with any underlying water damage event or condition and in a statistically significant manner.

As well, the role of legislation in producing housing improvements for health cannot be underestimated. For example, the literature confirms that housing changes that result in increased thermal comfort lead to health improvements and reduced absence from school or work24; while poor rental housing conditions and a lack of attention to repairs by landlords can amplify adverse health for tenants25.

6. What are the symptoms?

Clients who have requested an indoor air quality and mould assessment overwhelmingly report and display one or more of the following symptoms or issues which are drawn from verbal occupant histories taken at the beginning of each inspection. I list these in order of priority based on over 2000 inspections I have performed:

• sinusitis • rhinitis • cough • headache • wheeze • asthma • stuffiness

24 Thomson, H., Thomas, S., Sellstrom, E. and Petticrew, M. (2013). Housing improvements for health and associated socio-economic outcomes. Cochrane Database Syst Rev. 28(2): CD008657. 25 Horwitz-Willis, N. (2018). Health complaints associated with poor rental housing conditions in Arkansas: The only state without a landlord’s implied warranty of habitability. Front Public health. 6: 180.

16 • sneeze • cold and flu-like symptoms • general malaise • dermal skin infections • pneumonia • fatigue • long-term antibiotic use • non-attendance at work or study or reduced ability to leave the house due to acute or perceived illness • psycho-social concern including fear of illness, fear of contagion, fear of loss of personal property, loss of dignity, embarrassment and general distress • more acute psychological symptoms may include feelings of persecution or social isolation brought on by a feeling of helplessness due to inability to get stakeholders in the building to act on what they believe to be a very simple cause-and-effect relationship between water damage, mould and adverse health • neurological symptoms such as difficulty with recall or word finding • actual or suspected Lyme disease, chronic fatigue or gene defect as a co-condition • absence of evidence to support mould contamination despite personal claims of infestation (i.e. delusional parasitosis/Morgellan’s-type response)

In my opinion, the primary physiological response to indoor water damage and mould is a respiratory reaction. In many cases, making the correlation between an inhaled agent (e.g. mould spore, mould cell or mycelium or a cell wall fragment) is easily made when quantitative measurements are taken from within the suspect building.

7. How and what do we measure?

So therefore, how should buildings be assessed to collect suitable evidence on which to make a determination regarding both indoor air quality and the potential for water damage and mould to impact on the occupants? A range of different documents26,27, 28, 29,30, 31, 32 are available that explain how and when to perform a building inspection for mould with the view towards remediation or intervention to cause a return to low or normal mould levels.

This task will be performed by an occupational hygienist or someone qualified in microbiology, mycology or environmental health. A more liberal interpretation of the

26 New York City Dept Health Mental Hygiene. Guidelines on Assessment and Remediation of Fungi in Indoor Environments. New York: 2008. 27 ANSI/IICRC S500 Standard and Reference Guide for Professional Water Damage Restoration, 4th Edition, 2015. 28 ANSI/IICRC S520 Standard for Professional Mold Remediation, 3rd Edition, 2015. 29 ANSII/IICRC R520 Reference Guide for Professional Mold Remediation, 3rd Edition, 2015. 30 Kemp, P. & Neumeister-Kemp, H. (2010). Australian Mould Guideline. 2nd Ed. The Enviro Trust (AMG 2010) 31 Kemp, P. & Neumeister-Kemp, H. (2010). The Mould Worker’s Handbook – A Practical Guide for Remediation. 2nd Ed. The Enviro Trust. 32 WHO Guidelines for Indoor Air Quality (2009). Dampness and Mould.

17 skillset needed for mould assessment is provided by the IICRC R520-2015 that defines this role to be provided by an Indoor Environmental Professional (IEP). Different approaches for different buildings have been written about in both the citation and consensus literature which seek to encompass most aspects of the different options available for remediation. In all cases a walk-through to collect visual and easily acquired observations is the first step. It is important that all investigations develop a suitable sampling strategy to acquire quantitative data. These fall into three main types:

• air sampling, • surface sampling, and • bulk sampling.

Air samples usually take a known volume of air and collect this into a spore trap in order to count and speciate the different mould spores present in the sample. Other air sampling methods again take a known volume of air and pass this across the exposed side of a Petri dish to see what will grow using mechanical pumps or sedimentation directly from the air. Optical techniques include measuring the cumulative particle number concentration (particulate matter size distribution) based on size33 rather than mass using an optical particle counter34 since it has recently been found that large fungal fragments (>1µm) are under-sampled by traditional monitoring approaches, thereby underestimating actual fungal exposure35. Regardless of methodology, it is very important to collect suitable controls for the outdoor area as well as from the complaint/region of interest areas as well as those immediately adjacent to such areas. Suitable indoor controls which include non-complaint rooms or regions should be collected.

Surface sampling as its name suggests involves taking samples from visibly contaminated surfaces or from surfaces that might be contaminated through for example settled spores. Methods include sticky tape-type transfer slides or swabs to Petri plate or RODAC contact press plates.

Bulk sampling refers to collecting samples of actual building material such as insulation within walls, dust samples or water from air handling units. It is very important that the units used to quantify mould levels are consistent and that there is an effort towards report harmonization between different laboratories. As well, the sampling strategy used to assess the building conditions at the first inspection (ingoing assessment) should be well-matched with subsequent inspections. There is no point collecting a random set of data or under-sampling a building or worse yet, omitting appropriate

33 Izhar S, Rajput P, Gupta T. Variation of particle number and mass concentration and associated mass deposition during Diwali festival. Urban Clim 2018;24:1027:1036. 34 Lee JE, Lee BU, Bae GN, et al. Evaluation of aerosolization characteristics of biocontaminated particles from flood-damaged housing materials. J Aerosol Sci 2017;106:93–99. 35 Afanou KA, Eduard W, Laier Johnsen HB, et al. Fungal fragments and fungal aerosol composition in sawmills. Ann Work Expo Heal 2018;62:559–570.

18 controls. The aim of the initial inspection is to provide comprehensive data for the building as a whole. If the inspection relates to a residential property, and there are health and safety concerns, it is recommended to sample all habitable rooms. This makes it straightforward to compare like-with-like after cleaning and remediation and data sets should allow for easy comparison (at a glance) between the ingoing and outgoing condition. Because each sampling method measures different aspect of the fungal life cycle, more than one method should always be used, and care should be exercised in the taking of controls and matching sample locations.

The following list details the principal testing methods that have well documented standards or guidelines.

• Visual Inspection/environmental surveillance36 • Spore Traps37 • Tape Lifts38 • Surface Swabs39 • RODAC Contact Plates40 • Active & Passive Air Sampling41,42,43 • Airborne Particle Counting44 • Dealing with Statistical Uncertainty45

Despite the utility of these documents, Figure 6 suggests that there is still not enough research regarding the built environment and microbiological risk. This may be because most of the data ends up in building assessment-type reports and for use in civil litigation or for Insurance purposes – and less frequently in the clinicians office, although this is changing. If we look at the published literature for search terms like “water damage and indoor air” we see that there is increasing attention focused on indoor air quality (Figure 6), but the trends for “water damaged buildings” (Figure 7) or “mycotoxins and water damaged buildings” (Figure 8) is much less and shows a scattered distribution. This suggests many opportunities for important and targeted

36 Standard D7338-14 ASTM Standard Guide for Assessment of Fungal Growth in Buildings 37 Standard Test Method for Categorization and Quantification of Airborne Fungal Structures in an Inertial Impaction Sample by Optical Microscopy. ASTM International. Designation: ASTM D7391 – 17e1. 38 Standard Test Method for Direct Microscopy of Fungal Structures from Tape. ASTM International. Designation: D7658-17. 39 ASTM D7789-12. Standard Practice for Collection of Fungal Material from Surfaces by Swab. 40 Cleanrooms and associated controlled environments: biocontamination control. Part 1: general principles and methods. Document ISO 14698-1:2003. 2014, ISO 41 ISO 16000-17:2008, Indoor air Part 17: Detection and enumeration of moulds - Culture-based method 42 ISO 16000-18:2011, Indoor air Part 18: Detection and enumeration of moulds - Sampling by impaction 43 Cleanrooms and associated controlled environments: biocontamination control. Part 1: general principles and methods. Document ISO 14698-1:2003. 2014, ISO 44 ISO 21501-4:2018, Determination of particle size distribution -- Single particle light interaction methods -- Part 4: Light scattering airborne particle counter for clean spaces 45 ASTM D 7440-08 Standard Practice for Characterizing Uncertainty in Air Quality Measurements. (2015)

19 research and innovation that could be done in Australia on the topic of aeroallergen and biotoxin-related illness.

Figure 6. Number of published papers by year appearing in the PubMed database on the topic of “water damage + indoor air quality”. A linear regression trend line of best fit shows the popularity of this research area.

20 Figure 7. Number of published papers by year appearing in the PubMed database on the topic of “water damaged buildings”. A linear regression trend line of best fit shows the popularity of this research area.

Figure 8. Number of published papers by year appearing in the PubMed database on the topic of “mycotoxins + water damage”. A linear regression trend line of best fit shows the popularity of this research area.

8. CIRS – is it just a controversial illness category?

New terminology categories like chronic inflammatory response syndrome or CIRS are not without controversy. Because this Inquiry has already adopted the use of CIRS - it is important at this early stage to examine where this term originated and highlight that it is neither recognized nor has been made legitimate within medicine or the wider academic community. I shall discuss why since this is likely to become a fundamental communications issue for the Inquiry. The term CIRS appears to take advantage and springboard off the older term SIRS which stands for systemic inflammatory response syndrome46. SIRS has broadly developed from sepsis and infection control medicine and related inflammatory response issues for those conditions which are well accepted by the medical and wider scientific community. The novelty with the C-version of this term is that it substitutes the ‘chronic’ prefix for ‘systemic’, thereby assuming that a time-scaled cause and effect relationship exists.

46 Balk, R.A. (2014). Systemic inflammatory response syndrome (SIRS) Where did it come from and is it still relevant today? Virulence. 5(1): 20-26.

21 Reviewing the entire PubMed database reveals only 4 papers on CIRS and mould. Three of these are authored by Dr. Shoemaker47,48,49, while the other one is a single case report on one patient50. Although collectively these papers make some fascinating contributions to the water damage health literature, they fail to establish that all mould exposures result in inflammation or illness and in fact one of these papers fails to validate mould exposure in the home at all. Further, Dr. Shoemaker is to some extent ethically challenged51,52 and his ideas have been legally rejected53,54 for failing to make an adequate connection between mould exposure and illness. As well, the dominant corpus of information surrounding CIRS is linked to 2 patents55,56 held by Dr. Shoemaker regarding medical treatment and diagnosis, so the issue of conflict of interest cannot be underestimated.

Therefore, the Inquiry should be very mindful that controversial illness categories like CIRS do not become easily adopted or enter into common usage without appropriate consensus review from other academics and the wider medical community. CIRS is at best a fringe category adopted by a small group of activists57,58 that defer to social networks rather than the peer-reviewed literature. In turn, this continues to sustain internet-era medical misinformation and plays into imagined victimhood59 and illness

47 Shoemaker, R.C. and House, D.E. (2005). A time-series study of sick building syndrome: chronic biotoxin- associated illness from exposure to water-damaged buildings. Neurotoxicology and Teratology. 27(1): 29-46. 48 Shoemaker, R.C. and House, D.E. (2006). Sick building syndrome 9SBS) and exposure to water-damaged buildings: time series study, clinical trial and mechanisms. Neurotoxicology and Teratology. 28(5): 573-588. 49 Shoemaker, R.C., House, D. and Ryan, J.C. (2014). Structural brain abnormalities in patients with inflammatory illness acquired following exposure to water-damaged buildings: a volumetric MRI study using NeuroQuant®. Neurotoxicology and Teratology. 45: 18-26. 50 Gunne, S.R., Gunne, G.G. and Mueller, F.W. (2016). Reversal of refractory ulcerative colitis and severe chronic fatigue syndrome symptoms arising from immune disturbance in an HLA-DR/DQ genetically susceptible individual with multiple biotoxin exposures. American Journal of case reports. 11(17): 320-5. 51 Cohen, JS. [accessed July 27, 2018] Improper human study with veterinary drug. FDA warning letter—Ritchie C. Shoemaker MD. Casewatch. May 13. 2004 http://http://www.casewatch.net/fdawarning/rsch/shoemaker.shtml 52 Barrett, S. [accessed July 27, 2018] Richie Shoemaker, M.D., Reprimanded. http://www.casewatch.net/board/med/shoemaker/consent.shtml 53 Wajert, S.P. [accessed July 27, 2018] Mass Tort Defense - Daubert Decision in Mold Case. http://www.masstortdefense.com/2008/08/articles/daubert-decision-in-mold-case/print.html 54 Josephine Chesson, et al. v. Montgomery Mutual Insurance Co., No. 97, September Term 2012, Opinion by Battaglia, J. [accessed July 27, 2018]. https://www.wilsonelser.com/writable/files/Client_Alerts/chesson-v- montgomery.pdf 55 Methods for treating or inhibiting neurotoxin-mediated syndromes. https://patents.google.com/patent/US20030219400. Inventor Ritchie Shoemaker H. Hudnell Original Assignee Ritchie Shoemaker Hudnell H. Kenneth Priority date 2002-02-13 56 Methods for diagnosing, treating, and monitoring chronic inflammatory response syndrome. https://patents.google.com/patent/US20140046143. Inventor Ritchie Shoemaker Jimmy Ryan Original Assignee Ritchie Shoemaker Jimmy Ryan Priority date 2012-08-07 57 http://www.toxicmould.org/ 58 https://www.facebook.com/survivingmolddotcom/ 59 Campbell, B. and manning, J. (2014). Microagression and Moral Cultures, Comparative Sociology. 13(60: 692- 726.

22 categorization that is not always supported by objective health literacy60 despite communal or shared-identity validation benefits that such forums can provide for some groups61.

9. Unregulated testing methods

Other reasons why CIRS should not be allowed to become the default medical diagnosis or treatment term (or modality) is the fact that confirmation of mould exposure in people’s homes uses a non-standard sequence-based PCR method as a pre-cursor requirement before treatment62. The use of unvalidated laboratory testing, especially by Shoemaker, and the fact that certain diagnostic laboratories have interconnections, presents potential conflicts of interest for these doctors63. For example, the PCR test favored by Shoemaker certified physicians64 is the EMRI that stands for the Environmental Relative Moldiness Index. Firstly, this is the only method that does not have a Standard for application in indoor air quality testing for mould (see Section 7). Secondly, the patent holder for ERMI is the US EPA65 and they explicitly state that the test must not be used for routine use or diagnostic testing. However, and despite clear guidance from the EPA, Dr. Shoemaker and another lab in Australia66 routinely flout the facts that “ERMI should be used only for research” and should not be used for diagnosis or clinical interventions. This is largely because the ERMI method only shows a 48% agreement with other assessments, failed to detect mould in 52% of some homes and over-estimated the problem in other homes67. The method is also expensive and reductionist in that reports are often based on a single sample collected across multiple rooms of the home. This means there is use of non- uniform sample size collection and a host of other methodological problems.

ERMI results contain significant ‘method beautification’ where post-hoc analysis becomes pre-specified since there is tremendous focus on outcomes of analysis that favor the

60 Brady, E., Segar, J. and Sanders, C. (2016). “You get to know the people and whether they’re talking sense or not” Negotiating trust on health-related forums. Social Science & medicine. 162: 151-157. 61 Phillips, T. and Rees, T. (2018). (In)visibility online: The benefits of online patient forums for people with a hidden illness: The case of multiple chemical sensitivity 9MCS). Med Anthropol Q. 32(2): 214-232. 62 Shoemaker, R.C., House, D. and Ryan, J.C. (2013). Vasoactive intestinal polypeptide (VIP) corrects chronic inflammatory response syndrome (CIRS) acquired following exposure to water-damaged buildings. Health. 5(3): 10.4236/health.2013.53053 63 Auwaerter, P.G., Bakken, J.S., Dattwyler, R.J., Dumler, S., Halperin, J.J., McSweegan, E., Nadelman, R.B., O’Connell, S., Shapiro, E.D., Sood, S.K., Steere, A.C., Weinstein, A. and Wormser, G.P. (2011). Antiscience and ethical concerns associated with advocacy of Lyme disease. Lancet Infectious Disease. 11(9): 713-719. 64 Shoemaker protocol certification. [accessed July 27, 2018]. https://www.survivingmold.com/store1/shoemaker- protocol-module/shoemaker-protocol-certification 65 The Environmental Relative Moldiness Index: A Research Tool. [accessed 27 July, 2018]. http://paradigmchange.me/wp/urine/ 66 ERMI testing – MouldLab [accessed July 27, 2018]. https://www.mouldlab.com.au/ermi 67 Vesper, S., McKinstry, C., Cox, D. and Dewalt, G. (2009). Correlation between ERMI values and other moisture and mold assessments of homes in the American Healthy Homes Survey. Journal of Urban Health. 86(6): 850-860.

23 study hypothesis while ignoring shortcomings of the sampling bias68. What I mean here is that clinical use of ERMI is predicated on the notion that any result confirming mould will validate treatment despite serious shortcomings in translating ERMI to other countries where it only worked when 10 fungi were looked at and the rest of the data ignored69. Similarly, the HERTSMI-2 formalism (which is also a derivation of ERMI) intentionally sub- sets the data set thereby misreporting the results by allowing for selective reporting interpretations. Again, this leads into misleading interpretations and extrapolations that ignore the small study effect and lack of statistical analysis or significance testing. The severe deficits of ERMI as a consumer tool have also been reviewed by others70.

The fact remains that even if ERMI does red flag a mould problem this does not easily allow the occupants to know which area to remediate since the units of measure are not compatible with the other indoor air quality tests for mould that do have standards for interpretation. To address these problems, clinicians are being urged to become familiar with standard methods of indoor air quality testing71,72 used during home inspections and to use specific questionnaires during patient consultations73. Importantly, other very recent research74 is cautioning on the use of sequence-based methods like PCR for mould taxonomy classification due to reproducibility, and that it is actually harmful for mycology. At the end of the day, there is an imperative need to comprehensively link mould spores and their fragments with human exposure inside all areas of the home and not rely on surrogate or reductionist methodologies. Section 7 provided a list of established methods for mould assessment inside buildings.

10. Internet-era medical misinformation

Environmental illnesses are diverse and often toxicant loads are challenging for clinicians to assess in order to determine an accurate exposure history75. This very recent paper highlights many of the common information sources that are used by environmental medicine practitioners and draws attention to the need for standardized exposure

68 Boutron, I. And Ravaud, P. (2018). Misrepresentation and distortion of research in biomedical literature. PNAS. 114(11): 2613-2619. 69 Taubel, M., Karvonen, A.M., Reponen, T., Hyvarinen, A., Vesper, S. and Pekkanen, J. (2015). Application of the environmental relative moldiness index in Finland. Applied and Environmental Microbiology. 82(2): 578-584. 70 Rosen, G. (2015). Is ERMI testing being used for its intended purpose? (accessed 31/07/18). http://www.mold- toxins.com/ 71 Svajlenka, J., Kozlovska, M. and Posivakova, T. (2017). Assessment and biomonitoring indoor environment of buildings. International Journal of Environmental Health Research. 27(5): 72 Yang, C.S. and Heinsohn, P. (2007). Sampling and Analysis of Indoor Microorganisms. John Wiley & Sons, New Jersey. 73 Chew, G.L., Horner, W.E., Kennedy, K., Grimes, C., Barnes, C.S., Phipatanakul, W., Larenas-Linnemann, and D., Miller, J.D. Procedures to assist healthcare providers to determine when home assessments for potential mold exposure are warranted. (2016). J Allergy Clin Immunol Pract. 4(3): 417–422.e2. 74 Thines, M., Crous, P.W., Aime, C.M., Aoki, T., Hyde, K.D., Miller, A.N., Zhang, N. and Stadler, M. (2018). Ten reasons why a sequence-based nomenclature is not useful for fungi anytime soon. IMA Fungus. 9(1): 177-183. 75 Bijlsma, N. and Cohen, M.M. (2018). Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice. Environmental Health and Preventative Medicine. 23Z:19.

24 assessment tools linked with biomarkers. This is a positive step and further research should be encouraged in this direction.

Balanced against the rationalist view favoring transparency of information ranked according to its inherent truth-value we are unfortunately living in an era where there exists internet-driven medical misinformation, spin and fake news. Take for example the report of the death of a man from administration of Cholestyramine in an attempt to detoxify the patient from mould exposure76 despite only one reference77 to a non- Shoemaker published report that used this compound for treatment of toxicity caused by algal blooms. The other reported use of toxin binders78 used them to mix with mycotoxin- contaminated grains like nuts and cereals to reduce bio-accessibility of fungal mycotoxins in cattle. It is obvious that translating applied biotechnology from for example agriculture to medicine is risky not-withstanding the long list of serious or fatal side effects for Cholestyramine which have been reported79.

The issue of antiscience and the propaganda of persuasion is unfortunately alive and well with respect to mould equally as it is for Lyme disease63. Fake news80 takes advantage of misleading content to frame an issue, fabricate content, make false connections, or use false contextual information to establish a position. This can have a tremendous impact on choice-making in healthcare.

What is needed from this Inquiry are steps that diminish the threat that misconduct and the threat that opinion spam poses to science and society. It will be important that the Inquiry acknowledges that deliberate or unintentional misconduct contributes to irreproducibility and this is especially valid with respect to molecular techniques and biomarkers81. Notably, these are increasingly being used to assess mycotoxin-load from fungi measured from sera, urine, breast milk or direct extraction from human tissues82.

11. Improved terminology for healthcare providers

It would be more prudent to explicitly refer to any illness symptom that results from spending time inside water damaged buildings as a conditional result of chronic mould

76 Leibermen, C. (2015). Quack mold doctor and cholestyramine blamed in the death of a 64 year old man. (accessed 31/07/18). http://www.abnewswire.com/pressreleases/quack-mold-doctor-and-cholestyramine- blamed-in-the-death-of-a-64-year-old-ohio-man_33910.html 77 Hudnell, H.K. (2005). Chronic biotoxin-associated illness: multiple-system symptoms, a vision deficit, and effective treatment 78 Avantaggiato, G., Solfrizzo, M. and Visconti, A. (2005). Recent advances on the use of adsorbent materials for detoxification of Fusarium mycotoxins. Food Additives and Contaminants. 22(40: 379-388. 79 Cholestyramine side effects - from FDA reports. (Accessed 31/07/18). https://www.ehealthme.com/drug/cholestyramine/side-effects/ 80 Waldrop, M.M. (2017). The genuine problem of fake news. PNAS. 114(48): 12631-12634. 81 Bustin, S.A. (2014). The reproducibility of biomedical research: sleepers awake!. Biomolecular Detection and Quantification. 2:35-42. 82 Escriva, L., Font, G., Manyes, L. and Berrada, H. (2017). Studies on the presence of mycotoxins in biological samples: an overview. Toxins. 9(8): 251.

25 exposure causing oxidative stress. In fact, more recent and elegant work by an Australian research group83 shows that it is the sub-micron and nanoscale cell particulates and fragments that deliver mould toxins that react to highly specific components of the immune system. This is better defined as an ‘aeroallergen’ rather than a ‘biotoxin’ and this terminology has recently been adopted in Canada84 to reflect the diversity of challenge from biological and chemical component particles. The term oxidative stress is also more appropriate than CIRS in the context of water-damaged buildings and is supported by another recent publication85. At this early stage of public health discourse, one must be careful not to incorrectly conclude that water-damage automatically leads to inflammation which is entailed by the CIRS terminology. Other and arguably better experimental designs that have studied the possible connection between water damage exposure and inflammatory markers are careful to point out that inflammation is only a partial explanation for health symptoms86-87. There are also considerable mental health and psychological impacts/stressors that develop from living or working in dampness affected or flooded homes88 and offices and that cognitive impairment, although often cited, is not supported in the literature89 and may be better considered to be a method of coping with stress that follows over into a physiologic response.

12. Advocacy and health equity

For Policy to change health equity there is a need for targeted social justice and advocacy programs that can demonstrate economic benefits through timely public awareness. Without advocacy networks, there is no way to provide an unbiased ‘one-stop shop’ approach to deliver user-centric, customized advice and solution options. Because so much of the debate over cause and effect within the mould arena revolves around dispute resolution, it is logical to develop advocacy platforms that streamline common questions and answers using language that is legally defensible and evidence-based. The inquiry

83 Morris, G., Berk, M., Walder, K. and Maes, M. (2015). The putative role of viruses, bacteria, and chronic fungal biotoxin exposure in the genesis of intractable fatigue accompanied by cognitive and physical; disability. Mol. Neurobiol. 53(4): 2550-2571. 84 Sierra-Heredia, C., North, M., Brook, J., Daly, C., Ellis, A.K., Henderson, D., Hendesron, S.B., Lavigne, E. and Takaro, T.K. (2018). Aeroalergens in Canada: Disribution, Public health Impacts, and Opportunities for Prevention. International Journal of Environmental Research and Public Health. 15(8): 1577. 85 Somppi, T.L. (2017). Non-Thyroidal Illness Syndrome in Patients Exposed to Indoor Air Dampness Microbiota Treated Successfully with Triiodothyronine. Frontiers in Immunology. 8: 919. 86 Mustonen, K., Karvonen, A.M., Kirjavainen, P., Roponen, M., Schaub, B., Hyvarinnen, A., Frey, U., Renz, H., Pfefferle, P.I., Genuneit, J., Vaarala, O. and Pekkanen, J. (2016). Moisture damage in homes associates with systemic inflammation in children. Indoor Air. 26: 439-447. 87 Karvonen, A.M., Tischer, C., Kirjavainen, P.V., Roponen, M., Hyvarinen, A., Illi, S., Mustonen, K., Pfefferle, P.I., Renz, H., Remes, S., Schaub, B., von Muttis, E. And Pekkanen, J. (2018). Early age exposure to moisture damage and systemic inflammation at the age of 6 years. Indoor Air. 28(3): 450-458. 88 Lamond, J.E., Joseph, R.D., Proverbs, D.G. (2015). An exploration of factors affecting the long term psychological impact and deterioration of mental health in flooded households. Environmental Research. 140: 325-334. 89 Reinhard, M.J., Satz, P., Scaglione, C.A., D’Elia, L.F., Rassovsky, Y., Arita, A.A., Hinkin, C.H., Thrasher, D. and Ordog, G. (2007). Neuropsychological exploration of alleged mold neurotxicity. Archives of Clinical Neuropsychology. 22(40: 533-543.

26 should support development of multidisciplinary law-focused teams that can synthesize and broker the science, policy and practice to help with decision-making that favors health equality. Advocacy resources should demonstrate real-life context and describe actual and potential solutions. They should be actionable and not require specialized training or prior learning. They should foster collaboration and referral access to clinicians, allied health professionals, local service providers, policy makers and government and non- government institutions. Information portals that personalize or provide a user-centric Web 3.0 experience, including smart data aggregation, machine learning and decentralized ways to empower the individual to solve their own problems should be encouraged.

Recommendations regarding biotoxin-related illness in Australia

In order to properly approach the complex task of oversight and regulation of mould and water damage and improved health outcomes there is a need to address the following matters. I have broken this down into 6 recommendations:

1. Research

2. Education & Training

Training for persons carrying out practical mould remediation and assessment should be moved into the Vocational Education and Training (VET) framework. This is to enhance the calibre and delivery of quality educational content and ensure inclusion of local and international standards, guidelines and educational topics and perspectives. Private RTO’s currently offer non- accredited courses thereby leading to peer-driven consensus bias for the Industry as a whole. Establish online resources and other non-accredited training through incentives for partnership development with industry groups so information verticals can be linked with for example, the Continuing Professional Development system, to foster learning and engagement.

3. Real Estate

27 A working party should be setup to consult and focus on tenancy and owner- occupancy issues surrounding water damage and mould hygiene with the view towards development of checklists, assessment protocols, advice and advocacy options for all sta This should include representation spanning residential, commercial real estate, investment and property management, strata, social housing, disability and aged care along with mortgage lending/banking, insurance, remediation contractors, builders, individual trades and architects, HVAC specialists, medical/healthcare/scientific, legal and dispute resolution personnel.

4. Communications

5. Technical Standards & Guidelines

6. Mould Related Health and Water Damage Advocacy

28 platforms that are not based on social networks and encourage equity need to be encouraged. These could take the form of public-private partnerships, dot org community focused not for profits, online legal support, mediation and referral services through to whistleblower protections and risk assessment claims validation. Such platforms should be designed to scale and be interoperable into legislation, guidelines or codes of conduct and exploit emerging web 3.0 opportunities and decentralized and smart-data integrations.