Articulo 6

Chapter
AIRBORNE FUNGI AND BACTERIA IN PUBLIC INDOOR

ENVIRONMENTS
Manuela Oliveira1, Olga Maria Lage2 and Ricardo Araujo1

1
IPATIMUP; University of Porto; Rua Dr. Roberto Frias s/n,
4200 - 465 Porto, Portugal
2
Biology Department, FCUP and CIIMAR;
University of Porto; Rua do Campo Alegre s/n,
4169 - 007 Porto, Portugal
ABSTRACT
Indoor air quality has become an important part of occupational health and is a
relevant public safety issue. Although present throughout the year, airborne fungal spores
exhibit seasonal rhythms in occurrence and dispersion that depend on the type of climate,
availability of substrate and host-parasite interactions. Fungi can colonize almost
everything and find particularly favorable growth and spawning conditions in museums,
historic buildings and libraries. People working in “sick buildings” often experience
headache, shortness of breath, cough or nausea. Indoor moldy environments which can
cause asthma and other respiratory symptoms have been associated with significantly
higher spore counts. Bacteria such as Mycobacterium tuberculosis are associated with
airborne particles that are normally transmitted directly from human to human through
inhalation and can primarily affect the respiratory system. Other indoor sources of
microbes, such as Legionella pneumophila, are transmitted via aerosol-producing man-
made water systems such as showers, faucets, cooling towers and whirlpool spas and
organic dust that is the source of bacterial components like the endotoxin. In this chapter,
special attention will be given to the importance of airborne microorganisms in public
institutions, such as schools, hospitals or museums and to the concentrations and diversity
of microorganisms in indoor environments.

Manuela Oliveira: manuelao@ipatimup.pt
2 Manuela Oliveira, Olga Maria Lage and Ricardo Araujo
1. INTRODUCTION
People spend 90-95 % of their time indoors, either at work, such as business buildings,
factories, hospitals and other healthcare buildings, at school, at home, at places where leisure
activities can be pursued, such as museums, or in other public buildings, such as libraries or
churches. Thus, indoor air quality has become an important public safety issue. Knowledge of
the microbiota composition and of the environmental conditions that affect microbes has
become essential. Environmental factors influence the survival of airborne microorganisms;
bacteria are usually more susceptible than fungi, though bacterial endospores may be quite
resistant.
Because fungi are ubiquitous in indoor environments it is important to determine their
diversity. Fungi find particularly favorable growth and spawning conditions in museums,
historic buildings, and libraries. In these places, the presence of fungi is mainly associated
with the biodegradation and biodeterioration of cultural artifacts. Moreover, indoor
concentrations of fungal spores change between seasons, especially during summer and
autumn. Weather conditions, such as temperature, relative humidity or rainfall, affect the
sporulation, dispersal and deposition of spores and their fragments correlate with each other.
Fungi can trigger adverse effects to human health through three mechanisms: induction of
immune responses (e.g., allergy), invasive infection by the organism (e.g., aspergillosis) and
toxic effects (e.g., irritation by fungal byproducts like mycotoxins). People working in indoor
“sick buildings” often experience symptoms such as headache, shortness of breath, cough or
nausea.
Bacteria are abundant in aerosols. Several of the bacteria present in indoor environments
are human-associated, commonly found on skin and in nostrils, and normal gut microbiota;
alternatively, they may originate from outside environments. If the airborne bacteria are
pathogens such as Mycobacterium tuberculosis or Legionella pneumophila, or if the aerosols
contain bacterial components like endotoxins, then their inhalation contributes significantly to
the induction of airway inflammation and dysfunction. In this chapter the importance of
airborne microorganisms in indoor public institutions will be examined.
2. FUNGI
Fungi are members of a large group of eukaryotes that include microorganisms such as
yeasts and molds. Currently, more than 100,000 species of fungi have been formally
described. Those of interest in indoor environments belong to the class of Deuteromycetes or
Fungi Imperfecti, with a few exceptions (e.g. Mucorales, Ascomycetes, wood-rotting
Basidiomycetes and some yeast). The fungal spores present in the outdoor air influence the
presence of these bioparticles in indoor environments, but the indoor composition is not a
simple reflection of the outdoor air because indoor sources of spores may be present. In
deteriorated buildings with fungal contamination, one or two spore types may dominate the
air samples; fungi present in the outdoor air may be present at lower concentrations or even
absent.
New Bioindicators Sampling Procedures in Indoor and Outdoor Air Quality Control 3
2.1. Indoor Air Quality: Guidelines
Regarding indoor air quality studies, methods for collecting environmental samples of
biological contaminants and laboratory procedures for their analysis have not yet been
standardized. Thus, interpretation of the sampling data and their relation to health problems
must rely on researchers’ knowledge and experience until more data on dose-response
relationships to specific fungi become available [1]. Nevertheless some guidelines have been
proposed by different organizations worldwide. It has been generally proposed that: i)
qualitatively, the indoor and outdoor mycoflora should be similar and the indoor/outdoor ratio
should be lower than one; ii) the total fungal charge must be between 100 and
1,000 CFU m−3; and iii) the occurrence of both pathogenic species and indicator species for
excessive moisture should be further investigated [2-6] (Table 1).
In studies performed in order to explain causes of disease induced by fungi in the indoor
environment (case studies), it has been recommended that the first step should be to conduct a
"walk-through" of the building for visual and olfactory assessment of possible factors for
fungal problems, e.g. presence of visible dampness (including on furnishings), moldy spots,
condensation, leakage of pipes, penetration of rainwater, rising dampness and the presence of
heating, ventilating, and air conditioning (HVAC) systems [6]. Regarding fungal sampling, it
is recommended that the following strategies be employed: surface sampling to obtain
qualitative information about the fungal presence and air sampling to investigate whether
specific mold species are abundant in the indoor air. Usual analytical techniques include
gravimetric and volumetric sampling methods. Quantification of fungal spores can be
assessed either by culturing or direct cell counting. However, there are certain kinds of fungal
contamination not readily detectable by the methods presented above. Other identification
techniques, such as molecular or toxicological analysis, should be considered if the causative
agent of a fungus induced disease has not been identified.
2.2. Mechanisms of Release, Dispersal and Deposition of Fungal Spores
Depending on the availability of water and nutrients, fungi can grow on or in virtually
any substrate. In outdoor environments, fungi can be found primarily in decaying organic
matter and soil but they also colonize the tissue of epidermal structures of various plants [7].
In indoor environments, fungi grow on building materials rich in cellulose, ceilings and walls,
insulation materials and filters of heating, ventilation and/or air-conditioning systems [8-10].
Fungal spores present different morphological characteristics - namely, size, color and
shape - but also some different atmospheric release mechanisms. These mechanisms are
essential for spores to pass through the laminar layer of the atmosphere to reach the upper
layers where there are mass air movements (convection currents) [11]. The passive release of
spores occurs particularly in fungi that grow on living surfaces (e.g. powdery mildew, which
grows on plant leaves) where air breezes are able to penetrate sufficiently close to the
substrate to separate the spores. This phenomenon is aided by the formation of basipetal
chains. However, most fungal species have active mechanisms for the release of spores [11].
Table 1. Recommendations for indoor fungal spore concentrations in public indoor

environments
Organization Guidelines
Viable and non-viable particles should be considered during air-, dust- or
surface-sampling.
When heating, ventilating, and air conditioning (HVAC) systems are
present, sampling is recommended to evaluate whether filters are possible
sources of fungi for the indoor environment.
European Union Sampling of fungi should be performed when typical moldy odors are
reported and no mold growth is observed.
In cases of allergic reactions and respiratory complaints by occupants,
further investigation should be taken without any physical or chemical
reason.
The total fungi should be between 500 and 2,000 CFU m−3.
The indoor/outdoor ratio should be lower than 1.
American
The presence of an indicator species (i.e., fungi that indicate excessive
Conference of
moisture) or potentially pathogenic fungi (fungi that pose a specific health
Industrial
hazard) should be investigated.
Hygienists
The total fungi should be between 100 and 1,000 CFU m−3.
Significant numbers of certain pathogenic fungi should not be present in
indoor air (e.g., Aspergillus fumigatus, Histoplasma and Cryptococcus).
Bird or bat droppings near air intakes, in ducts or in buildings should be
assumed to contain these pathogens. Action should be taken accordingly.
The persistent presence of significant numbers of toxigenic fungi (e.g.,
Stachybotrys atra, and toxigenic Aspergillus, Penicillium and Fusarium
species) indicates that further investigation and action should be taken.
The confirmed presence of one or more fungal species occurring as a
Health Canada
significant percentage of a sample in indoor air samples and not similarly
present in concurrent outdoor samples is evidence of a fungal amplifier.
The "normal" air mycoflora is qualitatively similar and quantitatively lower
than that of outdoor air. In federal government buildings, the 3-year
average has been approximately 40 CFU m-3 for Cladosporium, Alternaria,
and non-sporulating Basidiomycetes.
More than 50 CFU m-3 of a single species (other than Cladosporium or
Alternaria) may present a reason for concern present.
Up to 150 CFU m-3 is acceptable if there is a mixture of species reflective
of the outdoor air spores. Higher counts suggest dirty or low efficiency air
filters or other problems.
Up to 500 CFU m-3 is acceptable in summer if the species present are
primarily Cladosporium or other tree and leaf fungi. Values higher than
this may indicate failure of the filters or contamination in the building.
The visible presence of fungi in humidifiers and on ducts, moldy ceiling
tiles and other surfaces requires investigation and remedial action
regardless of the airborne spore load.
Certain kinds of fungal contamination are not readily detectable by
conventional methods. If unexplained Sick Building Syndrome symptoms
persist, consideration should be given to collecting dust samples with a
vacuum cleaner and having them analyzed for fungal species.
Meteorological elements such as temperature, relative humidity, and rainfall, influence

the release of fungal spores, resulting in a seasonal or even a daily pattern in the atmospheric
composition of these bioparticles [11]. Thus, the concentration of dry weather spores, such as
Cladosporium spp., may increase at the beginning of precipitation: the movement and
vibration of air produced by droplets of water reaching the ground lead to resuspension of
deposited material. Studies have confirmed the release of ascospores after the increase of
relative humidity because the water creates turgor pressure that forces the output of the asci
[11].
Once released into the atmosphere, fungal spores are subjected to dispersal mechanisms
that cause their concentrations to decreases as they move away from the emission source [11].
Features such as spore morphology, density, and roughness may interfere with transport, as
these factors alter particle aerodynamics, thus modifying the speed at which they move [11].
Most bioparticles are deposited a few meters from the emission source. However, there is a
fraction that can remain suspended in the upper atmosphere and be transported for a few
miles before being deposited.
Human exposure to fungal spores may occur through several routes such as inhalation,
ingestion, and dermal contact. Humans inhale nearly 10 m3 of air day-1 and inhalation
constitutes the main route that results in adverse health effects. In general, deposition of
spores in the respiratory tract depends on airflow, the type of breathing (nasal or oral), and the
aerodynamic characteristics of particles [12]. When resorting to nasal breathing,
approximately 30-50 % of spores are deposited in the nose and 30-40 % reach the alveoli,
whereas when resorting to mouth breathing, approximately 70 % reach the alveoli. Deposition
occurs for approximately 20-30 % of particles at the level of the bronchi and 10.2 % in the
larynx [13]. The symptoms of allergic rhinitis and asthma may result from exposure to large
fungal spores (> 5 µm) such as Alternaria spp. and Stemphylium spp., which are deposited in
the nose or airway extra thoracic regions. However, hypersensitivity responses are more
related to the deposition of smaller spores (< 5 µm), such as Aspergillus spp., Penicillium
spp., and Cladosporium spp. in deeper regions of the airways such as the alveoli [14].
2.3. Exposure
The majority of our time is spent indoors, either at home, at work or at places of leisure.
In recent decades, indoor air quality has become an important occupational health and safety
issue. To avoid public health problems, losses of productivity, and reduced quality of life,
knowledge of the mycoflora composition of public buildings such as schools, hospitals,
museums, libraries, monasteries and churches is crucial to employ or develop more adequate
preventive. Moreover, it has been proven that, together with high moisture levels, the type of
construction material and the existence of air conditioning/heating devices also influences
spore concentration: for instance, fungal concentrations were higher in wooden schools than
in concrete schools [15, 16].
2.3.1. Schools
Schools are amongst the most studied and well-characterized indoor environments
worldwide, particularly in Scandinavia and the United States. The concern regarding these
public buildings may be associated with the susceptibility of children to fungal spores
induced disease, such as asthma and respiratory allergies. In this section, several examples are
presented of both building conditions and mycoflora compositions in schools ranging from
kindergartens/day-care centers [17-19], elementary/primary schools [3, 19-24] to
high/secondary schools [23, 25, 26] and universities [25, 27, 28].
Regardless of the type of school, the most frequent and dominant fungal spore present in
the indoor environment is Cladosporium, followed by Alternaria, Aspergillus, Penicillium,
and yeasts. Fungal spores such as Agaricus, Aureobasidium, Botrytis, Coprinus,
Chrysosporium, Fusarium, Ganoderma, Mucor, Scleroderma, Sporobolomyces, Stachybotrys,
Stemphylium, Trichoderma, Ulocladium, Rhizopus, Verticillium, and Wallemia may also be
found. However, some of these fungal genera are more associated with buildings damaged by
moisture [15, 29-31].
Spore concentrations (viable and total spore counts) in these buildings fluctuate widely.
Values ranging from less than 100 to nearly 1,000 CFU m-3 have been reported in the
literature, though in the majority of the analyzed buildings, the observed values were below
the safe threshold proposed by several international guidelines (1,000 CFU m-3) [20, 25, 27].
However, in schools with mold-related complaints such as asthma and respiratory symptoms,
significantly higher spore levels have been reported, sometimes reaching values of 50,000
CFU m-3 [18, 21, 24]. Special attention must be paid to nursery and elementary schools, due
to the presence of a variety of potential allergen reservoirs (e.g., upholstered furniture,
pillows, stuffed animals, and toys) that make the exposure levels higher in these classrooms
than what are found in middle and high school classrooms [32]. Moreover, at this early age,
children tend to be more physically active which greatly contribute to the disturbance of these
reservoirs [19]. Several reports not only reinforce the importance of airflows between indoor
and outdoor environments, especially when Cladosporium and Alternaria spores are
concerned, but also highlight the effects of human activity upon fungal concentration. Other
works point out to the importance of indoor sources, mainly in the cases of Aspergillus and
Penicillium spores as these are responsible not only for the induction on allergic responses but
also for the production of toxigenic compounds, such as mycotoxins and other harmful
secondary metabolites, which have an impact on human health [28, 33-35].
2.3.2. Hospitals
Qualitative and quantitative monitoring of indoor air fungi is usually problematic due to
the lack of standard and practical methods to continuously evaluate how indoor conditions
(ventilation, relative humidity, and temperature), outdoor environment and microscopic fungi
interact and affect each other. In hospitals, this interaction is highly relevant because airborne
fungi can be responsible for serious infections in several groups of immunocompromised
patients. It is rather complicated to associate outdoor fungal concentrations with the incidence
of infections in hospitals, but it is well known that outdoor fungi affect indoor fungal levels in
hospitals [36-40]. In addition, the decrease of indoor airborne fungi in concentrations may
correspond with a decrease in fungal infections in clinical units, particularly of A. fumigatus
[41-43]. One of the first studies reporting the absence of A. fumigatus infections in clinical
units was performed by Sherertz et al [44], which attributed tha lack of infections to fungal
levels lower than 0.1 CFU m-3. However, neither environmental breakpoints to completely
prevent fungal infections in clinical units nor the frequency for collection of air samples and
monitoring indoor air quality have been defined.
Indoor mold levels can be greatly reduced by air filtration systems, such as high
efficiency particulate air (HEPA) systems; the use of such systems results in a concomitant
decrease of invasive fungal infections [45]. A significant reduction of yeast-infections has
also been described in units with HEPA filters [42, 46]. A systematic review focusing on the
influence of HEPA filters in wards with immunosuppressed patients was reported by
Eckmanns et al [47], who concluded that HEPA filters could be occasionally beneficial for
patients. However, a significant decrease in fungus-related mortality rates was not found for
HEPA-protected areas. The installation of HEPA filtration systems is commonly associated
with positive pressures (>2.5 Pa) and air flow rates higher than 12 exchanges of air per hour
[48]. HEPA H13 filters retain 99.97 % of particles ≥0.3 μm, while fine filters (F7-F9) retain
approximately 90 % of particles. F8 and F9 filtration systems may also significantly improve
the air quality in clinical units, mainly in rooms with anterooms that limit the access of people
and where the use of protective clothes is mandatory [49].
Due to the huge clinical complications caused by fungal infections, studies have
evaluated indoor air quality in medical facilities worlwide. Airborne fungal values in clinical
wards without air filtration system range between 50 and 500 CFU m-3 [36-41, 50-52]. In
clinical wards with air filtration, airborne fungal values are much lower ranging from 0 to
50 CFU m-3. These indoor values may change if other restrictions are included with air
filtration systems. Multiple factors can affect indoor fungal concentrations, including the
presence of construction works, ventilation rates, people’s access to wards, the presence of
protective barriers, restriction to indoor fungal colonization, and the implementation of water
filtration [49, 53-55]. In general, the major challenge in clinical wards is to prevent the
entrance of ubiquitous outside fungi by keeping lower fungal concentrations in areas with
high-risk patients. The use of facial masks by patients in close contact with high-risk
environments can prevent infections [56].
Airborne fungal levels are significantly higher when clinical units are renovated or are
close to construction or building demolitions [50, 57, 58]. Strategically located portable
filtrations systems can also be used to microbial fungal airborne values [59, 60]. These
systems are useful alternatives in emergencies involving a complete breakdown of the fixed
air filtration system [48] and may also be used in places where fixed HEPA filtration systems
cannot be installed. Nevertheless, regular and appropriate maintenance of air filtration
systems is essential for maintaining excellent air quality in medical units. Newly engineered
made materials, such as silver- or cooper-impregnated materials, are expected to bring
improvements to hospital environments.
The assessment of indoor genetic diversity represents a very useful approach for
detecting specific clonal sources of some molds anywhere in a hospital, particularly for A.
fumigatus [61]. In fact, considering the huge fungal diversity usually found in indoor air, it is
assumed that a decrease of genetic diversity in a single room can indicate the colonization of
that environment with specific fungal strains. Indoors, the dispersion capacities of molds such
as A. fumigatus can be very difficult to control and limit once they reach the clinical units.
Thus, high-risk patients should be protected as much as possible from resistant or highly-
virulent strains. One of the biggest challenges in the near future will be to control microbial
dispersion, particularly of strains with higher pathogenic potential or with reduced
susceptibility to antibiotics. The presence of fungi in the clinical environment also affects the
health of hospital personnel. The complex of health troubles, negative feelings and general
discomfort due to staying in certain buildings is known as sick building syndrome [62]. The
minimization of fungal spore air loads garner considerable advantages regarding the health
statuses of the working personnel and the patients that frequent these facilities.
2.3.3. Museums and Libraries

Fungi play an important role in the deterioration of cultural heritage artifacts, both in
exhibited and stored art objects, frequently in both old and newly built museums [63, 64].
Because these microorganisms have an enormous enzymatic activity and can to grow at low
water activity values (aw, the ratio of the vapor pressure above a substrate to the vapor
pressure above pure water under the same conditions of temperature and pressure), they are
able to inhabit and to decay many materials used for historical art objects, such as paintings,
textiles, paper, parchment, leather, oil, casein, glue and other materials. Epi- and endolithic
fungi are heavily responsible for the increased in the weathering of stone monuments. To
prevent fungal contamination, museum exhibition and storage rooms must assure that
preventive measures such as climate control, cleaning and microbiological monitoring are
regularly performed. The Euascomycetes are the phylogenetic group more associated to the
deterioration of cultural heritage artifacts; Hemiascomycetes (yeasts) and teleomorphic forms
are more rarely isolated from art objects. The exceptions are Chaetomium spp., mostly found
on paper, wood and feathers, and Eurotium spp., present in environments with low aw values.
Basidiomycetes are usually restricted to wood degradation in churches or other protected
historical monuments. Finally, Zygomycetes are frequently isolated from pieces of art; in
most cases, however, they are transient species that are truly established on the objects [64].
At the Correggio exhibition in Parma - Italy, two sampling techniques were used in a study
performed in 2010. Air sampling revealed the presence of Alternaria, while settle plates
detected the occurrence of Fusarium spp. and Penicillium jenseni. A comparison was
established before and after the arrival of visitors; although some microbial contamination
was detected even before the arrival of visitors (99 CFU m-3), a significant increase was
recorded during opening hours (324 CFU m-3) [65].
To determine the possible role of fungi as allergic contaminants in some book collections,
air in the stacks of each of the eleven libraries of the University of Michigan was sampled on
three different occasions. During sampling, books were handled in half the samples. A
location in the same building away from book storage and an outdoor location were also
evaluated. Fungal taxa recovered from libraries, such as Alternaria, Aureobasidium,
Cladosporium, Epicoccum, Paecilomyces, Penicillium, and Trichoderma were similar to
those encountered in domestic interiors and outside in the study area. Aspergillus was the
exception being present only in indoor environments. However, outdoor levels consistently
exceeded indoor levels: library spore levels were generally low, except in the Museums
library. Moreover, air-conditioned libraries showed lower spore levels and indoor/outdoor
ratios than libraries without air-conditioning where windows were occasionally opened and
floor fans were used. Handling books during sampling increased spore counts in all libraries
[66].
2.3.4. Monasteries and churches

A few works have reported qualitative and quantitative assessments of fungal spores in
monasteries and churches. In these buildings, the presence of fungal genera is usually
associated with the biodegradation and biodeterioration of mural paintings (frescoes), painted
canvases and stone monuments. In all cases, the most frequent fungal genera were
Acremonium, Alternaria, Aspergillus, Cladosporium, Fusarium, and Penicillium [67-71].
However, the detection of these fungal spores in several kinds of artworks may be an
indicator of the airborne flora present in these buildings.
A study performed in the Cathedral of Santiago de Compostela - Spain, identified
Alternaria, Aspergillus, Cladosporium, and Penicillium as the most prevalent fungal genera
present. The same work compared the number of spores present in the air with the influx of
visitors in the Cathedral; the highest fungal scores detected correlated with a massive entrance
of visitors at 1 pm (406 CFU m-3) [72]. Lower values were detected in the church of Saint
Katherin Monastery – Egypt, during different visiting hours; the average fungal count was
90 CFU m-3 [73].
2.4. Health effects
Fungi can trigger adverse effects on human health through three mechanisms: induction
of immune responses, invasive infection by the organism and toxic-irritating effects caused
by fungal byproducts [74]. The prevalence and severity of these complaints in both children
and adults have been reported to increase when visible fungal growth is detected on indoor
surfaces and constructions. However, clear dose-response relationships between the presence
of fungal growth and disease complaints in damp buildings are still lacking mainly due to
difficulties in the assessement of fungal exposure and a lack of standardized protocols for
fungal sampling and analyses [75].
2.4.1. Allergy
2.4.1.1. Mechanisms of Allergy

Allergy is a hypersensitivity reaction initiated by immunological mechanisms after
contact with an allergen. Allergy can be antibody-mediated (humoral) or cell-mediated
(cellular; involves the activation of T-lymphocytes). In most cases, the antibodies responsible
for immune hypersensitivity to fungi belong to the immunoglobulin E (IgE) isotype (Type I
allergic reaction) and, more rarely, to the immunoglobulin G (IgG) isotype (type III).
IgE molecules and mast cells are concentrated in the mucous membranes; thus, IgE
antibodies are among the first defense molecules to face invaders. The distinctive feature of
the allergic response - immediate hypersensitivity - is mediated by the IgE-FcεRI complex
present in mast cells. The binding of IgE-FcεRI complexes on the surfaces of mast cells to
allergens triggers the "initial phase" of the allergic reaction, within minutes. This phase
involves the degranulation of mast cells and the synthesis of lipid mediators. Cytokines and
chemokines are released at this stage and begin the "late phase", which ends a few hours later,
and involves the recruitment and activation of inflammatory cells in areas sensitive to
allergens. Similarly, but without the more general symptoms described above, allergens also
trigger activated c proteins (ACPs) sensitive to IgE which, in turn, promote more production
of IgE by B-cells. The immunoglobulins serve to replace those spent during the allergic
reaction, thus maintaining sensitization of mast cells and ACP [76]. The recruitment of mast
cells and ACP and IgE production in the mucosal layers constitute the core functions of IgE,
along with the protection against systemic anaphylaxis. The precursors of mast cells are
produced in bone marrow and migrate to the mucosa before expressing FcεRI, which is
expressed in high copy number (approximately 500,000 copies per cell) under the regulation
of IgE. The concentration of immunoglobulin for the regulation of FcεRI in mucosal tissues,
is higher than that normally found in circulation. This increase is achieved through the
synthesis of IgE in B-cell sites. The rate at which this process occurs is sufficient to maintain
FcεRI expression levels on mast cells; any excess IgE is preferentially targeted for secretion
[76].
The prevalence of sensitization to airborne allergens depends on intrinsic characteristics
of the population (e.g., age and genetic predisposition), properties of the allergen (e.g.,
composition, duration, and intensity of exposure) and the geographic area in which the
exposure occurs. It is estimated that the prevalence of allergic respiratory diseases is 20-30 %
in atopic individuals, and approximately 6 % of the total population [77] (Table 2).
Differences in the prevalence of awareness among rural and urban areas have been reported
[78]. Individuals living in urban areas are more likely to develop respiratory symptoms than
residents in rural areas [79]. The evidence seems to indicate that urbanization, with high
levels of pollution due to vehicle emissions and the Western lifestyle, plays an important role
in the increasing frequencies of these diseases [80].
The diagnosis of allergic disease is based primarily on analysis of clinical symptoms
observed in patients, by testing for allergic sensitization (skin prick tests – SPT, or
intradermal tests - IDT), in vitro assay of specific IgE values circulating in the blood (e.g.,
radioallergosorbent test - RAST, enzyme-linked immunosorbent assay - ELISA, western blot)
and in some cases, provocation tests by inhalation of allergens [81, 82]. Recently, a new
principle for the diagnosis of allergies was developed. Purified or recombinant allergen
molecules, representing the major sources of allergic reactions, are placed on a pre-activated
glass slide, forming a microarray chip. This chip allows the determination of IgE and IgG
reactivity profiles in a single test and with very small quantities of serum. The main difference is
that this test uses allergen molecules as reactive species; other tests use extracts consisting of
mixtures of allergenic and non-allergenic molecules, hindering the identification of the
specific molecules capable of triggering allergic diseases [83-85]. Microarrays and ELISA
have similar analytical sensitivities, surpassing that of the RAST test [86].
Table 2. Sensitization and allergens from the fungal spores most frequent in the
atmosphere
Prevalence of Allergens
Fungal genera References
sensitization Number Molecular weight
Alternaria 3-32 % 13 11-70 kDa [183-189]
Aspergillus 5-29 % 37 11-105 kDa [188-192]
Epicoccum 5-15 % 2 26-30 kDa [188, 193-195]
[188, 191, 192,
Penicillium 7-14 % 7 11-105 kDa 196]
[187-189, 191,
Cladosporium 1-24 % 14 8-70 kDa 192]
2.4.2. Infection
Fungi can cause a large number of infectious diseases ranging from superficial skin
lesions to life-threatening systemic mycoses. Immunocompromised patients are at the highest
risk for development of fungal infections in hospitals. The complete list of fungemia risk
factors is vast, but the most relevant factors are: i) subjection of patients to
immunosuppressive treatments, such as chemotherapy or corticosteroids therapy; ii)
neutropenia with < 500 polymorphonuclear cells ml-1; iii) treatment with antimicrobial drugs;
iv) subjection to bone marrow or solid organ transplants, extensive surgeries or burns, v)
presence of indwelling catheters; vi) need for parenteral nutrition, assisted ventilation or
hemodialysis; vii) previous fungal infection; and viii) malnutrition [87, 88]. The most
important fungi responsible for infection in these patients are species of Candida, Aspergillus,
and several Zygomycetes. In addition, emerging fungal pathogens (Fusarium sp.,
Scedosporium sp., Thichosporon sp., and Malassezia sp.) are also becoming threats to high-
risk patients. These molds are angioinvasive and lead to extensive tissue infarction and
widespread dissemination.
The immunocompromised population has dramatically increased in the last decades and
the numbers of deaths attributed to mold diseases has concomitantly increasesd. Invasive
aspergillosis is the most common airborne mold infection and generally involves inhalation of
conidia or hyphae and further fungal growth in the human internal milieu. Boswell et al [45]
reviewed all cases of invasive aspergillosis and concluded that the fungus is capable of
causing disease in environments with less than 1 CFU m-3 of air. It is recommended that high-
risk patients should be protected from fungal exposure and that distinct transmission routes
should be monitored. Patients staying in clinical units for long periods with high-degree and
long durations of immunosuppression are at the highest risk for developing invasive
aspergillosis. In hematological patients, the incidence of fungal infections is higher in patients
suffering from acute leukemia and aplastic anemia malignancies [42, 89]. Nosocomial
aspergillosis occurs generally via the air, but the involvement of water [90], plants [91],
equipment [92] or even person-to-person contact [93] have been confirmed in molecular
studies. For highly protected wards, a list of recommendations was issued in 2003 by the
Center for Disease Control and Prevention (CDC) and the Healthcare Infection Control
Practices Advisory Committee (HICPAC) is currently available for free consulting [48].
Staff, patients, and visitors should be continuously reminded of the necessity for routine
hand hygiene to prevent infections in healthcare facilities [54]. Pillows and food, which have
been previously shown to represent important reservoirs for fungi, should be monitored for
quality [94, 95]. Patients are advised to remain isolated as long as their immune systems are
compromised; thus, diagnostic procedures should be conducted into protected wards. Patients
and staff should be continuously aware regarding procedures performed in restricted
environments. In fact, the implementation of educational programs could result in the
reduction of infections in clinical wards [96].
Construction and renovation of clinical departments must been carefully planned, as these
interventions can result in an increase of infections in hospitals. Inadequate ventilation and
proximity to renovation and construction sites have been repeatedly implicated in the
epidemiology of fungal infections, especially invasive aspergillosis [50, 60, 97]. Hospitals
surrounded by construction sites are usually exposed to higher levels of airborne particles and
additional protective measures should be followed. If large renovation works take place in
units admitting high-risk patients, the patients should be transferred far from construction
sites. Sodium hypochlorite is commonly used for cleaning walls and surfaces in wards, but
other chemicals possessing fungicidal activity against most yeasts and molds can be used as
disinfectants [98, 99]. Reference airborne fungal values are still not widely defined; the
establishement of such reference values is critical for the proper monitoring of clinical
environments and the protection of high-risk patients.
2.4.3. Mycotoxins
Mycotoxins are produced by a large number of fungal genera as secondary metabolites,
that are not essential for the organisms’ livelihood but are able to trigger various changes and
pathologies in animals, including humans [100]. A given species of fungus can produce
various mycotoxins and, paradoxically, a mycotoxin may be produced by different species of
fungi. Almost all mycotoxins are cytotoxic and can lead to the disruption of cell membranes,
or interfere with vital processes such as protein, RNA or DNA synthesis. Thus, these
molecules are usually carcinogenic, mutagenic or neurotoxic.
Currently, there are between 400 and 500 known mycotoxins; the most relevant to human
health, due to the high toxicities are aflatoxin, ochratoxin, sterigmatocystin, fumonisins,
trichothecenes, patulin and citrinin. There are approximately 14 identifiedaflatoxins, produced
by several species of Aspergillus [101, 102]. Several foods may be contaminated with these
mycotoxins, including figs, tobacco, peanuts, nuts, peas, bread, cheese, rice, corn, rye,
sorghum, wheat, oilseeds, and cotton; additionally, milk eggs and the liver of pigs fed
contaminated food may contain these mycotoxins [103]. Among the effects of ingestion and
inhalation of aflatoxin, standout include acute necrosis, cirrhosis, and liver cancer in several
animal species (also referred to as mutagenesis, immunosuppression and cancer in animals)
[103, 104]. In humans, these compounds act as potent carcinogens [102]. Ochratoxin A is
synthesized by Aspergillus ochraceus, Penicillium verrucosum and, although in smaller
quantities, Aspergillus niger [101]. These mycotoxins can be found in many cereals, coffee
and bread. In animals, they are considered nephrotoxic, hepatotoxic, immunosuppressive,
teratogenic, and carcinogenic. In terms of human health, its carcinogenic potential has been
confirmed by the International Agency for Research on Cancer. It is thought that these
mycotoxins are involved in Balkan nephropathy, a form of nephritis characteristicto the
population surrounding the River Danube in parts of Romania, Bulgaria, and former
Yugoslavia [102]. Sterigmatocystin is produced by 12 species of Aspergillus, Chaetomium
spp., and Penicillium luteum and is a natural contaminant of barley, rice, and wheat but also
can be found in diets based on corn and cotton seed [105]. These compounds have
nephrotoxic, hepatotoxic, mutagenic and carcinogenic effects [102, 106, 107]. Fumonisins are
synthesized by different Fusarium species and, to a lesser extent, by A. alternata. They occur
sporadically, in foods such as sorghum, asparagus, rice, beans, and beer. Trichothecenes are
among the mycotoxins with greater toxic potential and therefore the most studied secondary
metabolites. Currently, approximately 148 different trichothecenes have been isolated from
species of Fusarium, Myrothecium, Phomopsis, Stachybotrys, Trichoderma, and
Trichothecium, among others [108]. They are contaminants of corn, barley, oats, rye, wheat,
and safflower seeds. At an early stage of exposure, these mycotoxins are capable of producing
gastrointestinal and respiratory symptoms, followed by anemia, leukopenia,
thrombocytopenia and, in cases of prolonged exposure, tissue necrosis accompanied by
respiratory and gastrointestinal bleeding and infectious complications [103, 109]. Patulin,
synthesized by several species of Aspergillus, Byssochlamys and Penicillium, is a common

contaminant in products derived from fruits and vegetables [110]. These compounds induce
bleeding in different organs and are associated with immunosuppression and increased
susceptibility to infectious diseases [110, 111]. Citrinin is synthesized by different species of
Aspergillus, Monascus, and Penicillium. This mycotoxin is found in wheat, oats, rye, corn,
barley, and rice [102]. These compounds have proven nephrotoxic effects [112], however,
their effects as carcinogen are still controversial [113].
There are at least four mycotoxins known that have great utility for man: penicillin,
cephalosporins, ergotamine and cyclosporine A. Penicillin, discovered by Alexander Fleming
in 1928 and produced by Penicillium chrysogenum (or P. notatum), is widely used to combat
bacterial infections [114, 115]. Cephalosporin, isolated by Giuseppe Brotzu in 1946 from
Acremonium chrysogenum (formerly Cephalosporum acremonium) is applied to combat
infections caused by bacteria resistant to penicillin [116, 117]. Ergotamine and other
compounds from the ergot family of alkaloids are produced by Claviceps purpurea and acts
as a vasoconstrictors that are used therapeutically for the treatment of acute migraine attacks
[118, 119]. Cyclosporin A, discovered by Sandoz in 1971 and isolated from Tolypocladium
infiatum, is an immunosuppressive drug with specific action on T-lymphocytes; it is widely
used in surgeries involving organ and tissue transplants to reduce the chances of rejection
without the undesirable side effects of other drug used for the same purpose [120, 121].
Mycotoxins must certainly be regarded as among the many potentially hazardous factors
present indoor in both homes and non-industrial environments. However, their real impact on
human health has never been satisfactorily assessed.
3. BACTERIA
The quality of the indoor environment is very important for human well being, as we
spend most of our lives in homes, day-care facilities, schools and work places. The effects of
our contact with microorganisms are mediated not only through infection but also through the
development of indigenous human microbiota during infancy, prevention of allergic
conditions in childhood and adverse health symptoms in adulthood. The influence of bacteria
as potential risk for the public health of indoor environments is still poorly understood.
3.1. Indoor Concentrations and Diversity of Airborne Bacteria
Indoor sources of bacteria in bio-aerosols can come from air systems, surfaces such as
walls, ceilings, carpets, and houseplants, operating rooms and the aeration tank and active
sludge in water treatment plants. Significant levels of bacteria are present in indoor public
environments like office buildings, schools and daycare centers. Our knowledge of the
compositions and concentrations of the microbial communities present is still scarce and
mainly based on culture-dependent methods. These have several limitations and the number
of bacteria obtained is very much underestimated [122]. Expected concentrations of bacteria
vary from 10 to 106 CFU m-3 [123]. In the bioaerosols from a duck hatchery, Martin and
Jackel [124] found values of 6 × 101 and 7 × 106 CFU m-3 of culturable bacteria,
corresponding to 2 × 107 cells m-3 of total cell counts of DAPI-stained cells. Bouillard et al
[125] detected bacterial levels in the air in carpeted offices (44-450 CFU m-3), synthetically
floored offices (122 - 794 CFU m-3), nursery schools (428 - 2,511 CFU m-3), and gymnasium
(1,572 CFU m-3). In settled dust, bacterial levels in carpet range from 0.73-185 × 105 with
7.28 × 105 CFU g-1 as the median value. Concentrations of aerosolized culturable bacteria of
occupied classrooms of a suburban elementary school in Columbia, SC ranged from 262-
997 CFU m-3 [126]. In the aerosols of a hospital therapeutic swimming pool, Angenent et al
[122] found approximately 106 microbes m-3, corresponding to several hundred microbes per
inhalation. The concentrations of bacteria in a general Korean hospital varied between the
different locations sampled, with the highest values obtained in the main lobby (226 CFU m-
3
) [127]. Airborne microbe values of 38.6 and 19.3 CFU m-3 were registered in the exhibition
hall of a museum (Lee et al. 2010).
Both Gram-positive and Gram-negative bacteria are commonly found in indoor air
although Gram-positive bacteria seem to dominate when culture methods are used for
detection. Dust-born bacterial diversity in schools and children's day care centers contained
mainly bacilli and Actinomycetes and animal sheds contained mainly the Gram-negative
genera Pseudomonas, Pantoea, Flavobacterium and Xanthomonas or Bacillus, Micrococcus
and mesophilic and thermophilic Actinomycetes depending on the season [128]. In a general
Korean hospital Staphylococcus spp., Micrococcus spp., Corynebacterium spp. and Bacillus
spp. were encountered [127]. Bouillard et al [125] identified Enterococcus, Staphylococcus,
Pantoea and Pseudomonas as the most abundant bacterial genera in the carpet dust in healthy
offices and Micrococcus spp. and Staphylococcus spp. in air samples. Antibiotic-resistant
Staphylococcus aureus was commonly reported in the indoor air of normal residential
buildings, even though infectious agents normally cannot persist for a long time in air [129].
Mycobacteria, streptomycetes and Nocardiopsis spp. are Gram-positive bacteria that possess
either strong immunogenic properties or potential toxin production and have been shown to
be present in indoor environments [130-132]. Species of Pseudomonas and Bacillus are the
most common airborne bacteria present in museum [133]. Less abundant species include
Acinetobacter, Streptococcus, Neisseria, Micrococcus and Staphylococcus.
Recently, molecular methods based on 16S ribosomal DNA clone libraries have been
applied to the study of bacterial microbiota in indoor environments and have expanded our
understanding of bacterial diversity. The number of operational taxonomic units (OTUs)
found is much higher than the number of isolates identified via culture methods [134]. In air
samples from two shopping centers in Singapore, Tringe et al [135] estimated the presence of
170 to 300 distinct species of Brevundimonas, bacteria affiliated with the prevalent organisms
Caulobacterales and Stenotrophomonas maltophilia. Phylotype groups, such as
Brachybacterium, Acinetobacter, and members of Microbacteriaceae and Micrococcaceae
were also found. In the biofilm of shower curtains, Sphingomonas spp. and Methylobacterium
spp. were the most often present [136]. McManus and Kelley [137] assessed bacterial
contamination in airplane environments and observed that the most frequent genera were
Streptococcus, Staphylococcus, Corynebacterium, Proprionibacterium and Kocuria. These
are commonly associated with humans and are found in indoor dust. In a child-care facility,
the Gram-negative Pseudomonadaceae and Oxalobacteraceae were the most dominant
families identified, but Gram-positive genera, such as Bacillus, Streptococcus and
Staphylococcus were also present [134]. Furthermore, in this study, many human-associated
bacteria including a number of pathogens and opportunist pathogens were detected.
Additionally, Angenent et al [122] found a noteworthy abundance of Mycobacterium avium

sequences in the air samples from a hospital therapy pool area. Rintala et al [138] investigated
the bacterial diversity and seasonal dynamics in indoor dust in the office rooms of two
buildings. The microbiota of dust bacteria was dominated by Gram-positive species, the most
abundant phyla being the Firmicutes: Corynebacterium-, Propionibacterium-, Streptococcus-
and Staphylococcus-sequences comprised the most-represented OTUs. Regarding Gram-
negative bacteria, the most abundant of the OTUs included members of the
Sphingomonadaceae family, followed by Oxalobacteraceae, Comamonadaceae,
Neisseriaceae and Rhizobiaceae. The dominant phylotypes most likely originated from users
of the building. Potential and opportunistic pathogens like Enterococcus faecalis, Moraxella
osloensis, Staphylococcus haemolyticus, Mycobacterium, Rothia dentocariosa, and Shigella
flexnerii are often reported in studies [134]. Several of the bacteria present in indoor
environments are human-associated and are commonly found on skin and in nostrils and
normal gut microbiota or originated from outside environments.
Several airborne bacteria that cause disease in humans have also been identified, such as
Bordetella pertussis (whooping cough), Chlamydia psittaci (psittacosis), Corynebacterium
diphtheria (diphtheria), Chlamydia pneumoniae (pneumonia), Mycoplasma pneumonia
(pneumonia), M. tuberculosis (tuberculosis), Neisseria meningitidis (meningitis),
Streptococcus spp. (pneumonia and sore throat) and Legionella pneumophila (legionellosis).
In these diseases, microorganisms are associated with airborne particles that are normally
transmitted directly from human to human through inhalation and primarily affect the
respiratory system. Due to their importance and their presence in indoor environments, the
organisms responsible for tuberculosis, legionellosis and endotoxin-related disease will be
addressed in detail.
3.2. Mycobacterium tuberculosis
Tuberculosis (TB) is a significant disease because of the number of people infected by its
causal agent (approximately one-third of the world’s population) and the number of death
caused (1.5 to 2 million people per year) [139]. TB is one of the leading causes of deaths of
all infectious diseases worldwide [140]. Only in the nineteenth century was this ancient
malady established as a disease and its causal agent, M. tuberculosis, discovered by Robert
Koch. Many advances have been achieved in the understanding and treatment of TB, such as
the immunization using the attenuated bovine-strain TB (BCG - Bacillus of Calmette and
Guérin); also, an effective treatment was identified with the development of the antibiotic
streptomycin. However, the complete eradication of TB has failed due to the appearance of
multidrug-resistant strains of M. tuberculosis in the 1980s. Furthermore, the emergence of
health conditions that deplete the immune system, such as human immunodeficiency virus
(HIV), chemotherapy or even stress, has led to the resurgence of TB. This disease remains a
global health problem but is especially prevalent in developing countries. Hospitals and other
health care environments, homeless shelters, schools, prisons and office buildings - places
where people are confined in enclosed spaces - are ideal to foster TB epidemics. In countries
like the United States, where TB incidence had previously declined, the disease is now
becoming more prevalent in homeless, elderly, malnourished, alcoholic, minority, immigrant,
prison, HIV-infected and drug-using populations.
TB is caused by bacteria of the genus Mycobacterium, which are non-motile, slow

growing, obligate aerobes with pleomorphic rods; they are also designated acid-fast bacilli.
The Ziehl-Neelsen staining procedure is a commonly used diagnostic method for
mycobacterium identification. Several species can cause TB in human and other animals. In
the M. tuberculosis complex (MTC) M. tuberculosis, M. bovis, M. africanum and M. microti
[141] can cause TB. The M. avium complex (MAC) comprised of two closely related species,
M. intracellulare and M. avium, and has become the more prevalent mycobacterial agent of
TB in AIDS patients in the U.S. [142]. The most commonly used test for the detection of TB
is the tuberculin skin test (TST) or the Mantoux method, which involves the intradermal
administration of 5 tuberculin units of purified protein derivative. The result, read as the
transverse diameter of induration recorded in millimeters, should be measured after 48–72 h.
New tests have been developed, such as the nucleic acid amplification (NAA) test that can be
performed on direct specimens, and QuantiFERON-TB Gold (QFT-G), an in vitro test that is
based on the quantification of interferon-gamma (IFN-γ) secreted from stimulated T-cells
previously exposed to M. tuberculosis [143]. However, for the definitive diagnosis of
pulmonary TB, it is necessary to culture mycobacteria from infected secretions or tissues
which allows for the drug susceptibility testing that is essential to establish the treatment.
Mycobacteria can be found in soils, water, house dust and livestock. Some are facultative
intracellular pathogens usually infecting mononuclear phagocytes (e.g. macrophages). TB is a
highly contagious, airborne respiratory disease that is especially prevalent in small indoor,
poorly ventilated spaces. The transmission of the disease occurs via infectious droplet nuclei
(1 to 5 µm in diameter) expelled by active pulmonary TB sufferers, which then reach the
respiratory track of susceptible individuals. These particles can be aerosolized by coughing,
sneezing, talking, or singing. A cough and a sneeze can generate respectively approximately
3,000 and 40,000 droplet nuclei [144]. In general, infectious microorganisms range from 0.3
to 10 µm in diameter for bacterial cells and spores; M. tuberculosis specifically measures
approximately 0.3 to 0.6 x 1 to 4 µm [144]. For an effective infection of TB only a few cells
of M. tuberculosis, are needed. The nature of their resistant cell wall structure is essential to
overcome the normal lung clearance mechanism in a susceptible host.
When reaching the alveoli of the lungs, the tubercle bacilli are phagocytosed by alveolar
macrophages, and the majority are destroyed after the fusion of the phagosome with
lysosomes (phagolysosome). A small number of virulent bacilli escape the lysosomal fusion
and become confined in granulomas, or else they may multiply and spread to other organs
(kidneys, brain, bones and lymph nodes) through the lymph and the bloodstream. In this
situation a systemic response can be induced. The progression from a latent TB infection to
TB disease can occur soon after infection or many years after. Conditions associated with
progression to active TB include malnutrition, alcoholism, poorly controlled diabetes
mellitus, silicosis, immunosuppression, the postpartum period, gastrectomy, chronic
hemodialysis, and jejunoileal bypass surgery [145]. TB symptoms include fever, night-time
sweating, weight loss, persistent cough, constant tiredness and loss of appetite. TB treatment
can be divided into two groups. First-line agents include isoniazid (INH), rifampicin (RMP),
pyrazinamide (PZA) and ethambutol (EMB); second-line agents include fluoroquinolones,
such as levofloxacin and moxifloxacin.
3.3. Legionella pneumophila

Legionellosis, which may present as Legionnaires' disease or Pontiac fever, represent two
clinically distinct forms of illness mainly due to the infection with L. pneumophila. This
nutritionally fastidious, Gram-negative, aerobic, flagellated, rod-shaped
Gammaproteobacteria causes, respectively, pneumonia and a milder form of respiratory
illness. Legionnaires' disease derives its name from an outbreak of Legionella infections at
the 1976 Legionnaires' Convention in Philadelphia, after which it became considered a
disease by the U.S. Centers for Disease Control [146]. It is a form of pneumonia that can be
either sporadic or epidemic and either community-acquired, nosocomial-acquired or travel-
related [147, 148]. Legionella can cause morbidity and mortality in both healthy and
immunosuppressed humans, the latter of which are at grave risk if infected. Clinically, the
pneumonia caused by Legionella is difficult to differentiate from pneumonias caused by other
microorganisms though some diagnostic symptoms are more specific. The majority of cases
of legionellosis are due to L. pneumophila serogroup 1 but of the 53 species[149] and 72
serogroups known, approximately half can cause disease mainly due to opportunistic
pathogenicity [150]. Among other Legionella spp., L. longbeachae, L. bozemanae, L.
micdadei, L. dumoffii are the most common human pathogens [151].
Reports of a significant increase of the disease in the last years have come from the U.S.,
Europe (namely Germany and Spain) and Australia [150, 152]. The introduction of the
Legionella urinary antigen test has allowed for a simple, specific and fast disease diagnosis
[153] and has aided in the decrease in mortality observed over the last years [147, 154, 155].
The disadvantage of this method is the lack of specificity to organisms other than L.
pneumophila serotype 1. Other methods for the identification and diagnosis of L.
pneumophila are the culture of microorganisms on buffered charcoal yeast extract (BCYE)
agar medium and PCR-based assays. The antibiotic therapies currently used for the treatment
of L. pneumophila infection, azithromyccin and fluoroquinolones, have also facilitated the
reduction in fatalities.
Legionella spp. are present in all freshwater environments worldwide but natural water
bodies are not implicated in human transmission. Sources of transmission are generally man-
made indoor water systems like showers, faucets, cooling towers and whirlpool spas that can
produce aerosols from contaminated waters [151, 156-158]. Warm to hot water (20 - 45º C)
stimulates the growth of bacteria and aerosolized droplets serve as vehicle. Aerosol
concentrations near a whirlpool spa during an outbreak have been estimated to be 5-18 CFU
m-3 [159]. Transmission does not occur from person to person. After inhalation, Legionella
spp. cause heavy inflammatory infiltration consisting of neutrophils and macrophages,
necrosis, abscess formation and inflammation of small blood vessels [160].
Legionella spp. are parasites of protozoa, their natural hosts. They parasitize at least 20
species of amoebae, 2 species of ciliates and one species of slime mold. They can live freely
in biofilms, such as those covering the interiors of pipe walls [150] where they can proliferate
via their interaction with protozoa. The capacity of Legionella to survive and reproduce
within protozoa plays an important role on their pathogenesis. Similar events occur for the
recognition and phagocytosis of Legionella by both protozoa and mammalian macrophages,
evidencing evolutionarily conserved cell biology [161]. Cells divide inside membrane bound
compartments designated Legionella-containing vacuoles (LCV); the bacteria possess a
bacterial type IV secretion system, the Icm/Dot system, which is fundamental for the
translocation of molecules into the host cell cytosol [162].
Prevention of legionellosis can be achieved through adequate measures to monitor,

identify and eliminate the bacteria at their environmental source. Spread of the disease can
then be controlled and the number of cases significantly decreased. Special attention should
be paid in high-risk places, such as healthcare facilities. Chlorination,the heating of water
above 59º C, silver-copper ionization of water, and strict cleaning procedures for water
systems are prevention strategies that can control the spread of Legionella [148].
3.4. Airborne Endotoxins
Gram-negative bacteria possess complex cell walls composed of a peptidoglycan layer

and an outer membrane. Lipopolysaccharide (LPS), a large, complex molecule, is located on
the external side of this membrane. LPS contains both lipids and carbohydrates and consists
of three parts: lipid A, the core polysaccharide and the O-specific side chain. Due to the
toxicity of the lipid A portion, LPS is also designated an endotoxin. It can be released into the
environment upon division or lysis of the microorganisms and can induce an inflammatory
response after inhalation affecting both humoral and cellular host mediation systems [163,
164]. The production of the inflammatory mediators interleukin 1 (IL-1), IL-8 and tumor
necrosis factor (TNF) then increases [165]. Endotoxin interacts with different human cell
types, such as basophils, mast cells, endothelial cells, macrophages, platelets,
polymorphonuclear leukocytes, and T and B lymphocytes [164]. Acute and chronic exposure
to endotoxin can induce acute and chronic effects in humans. Symptoms induced by
endotoxin can include cough, fever, shaking chills, septic shock, bronchial inflammation,
toxic pneumonitis, lung function decrements and respiratory symptoms, such as byssinosis
(“Monday morning chest tightness”) [166, 167]. Chronic symptoms include nonatopic
chronic obstructive pulmonary disease (COPD) [168], emphysema, chronic bronchitis and
asthma [169]. Endotoxin has important impacts on allergic diseases [169]. Evidence suggests
that early-life exposure to endotoxin protects against allergy development and asthma as
endotoxin can elicit a T-helper type 1 (Th1) response or a dampening of the T-helper type 2
(Th2) response. The dual positive and negative effects of endotoxin in asthma are likely due
to time- and dose-exposure factors and the variable interaction of genes with the environment
[169]. Protective effects of endotoxin exposure are also reported for atopy in adults [170-
173]. Furthermore, endotoxin may exhibit antitumor properties in the lung and, possibly, for
other cancers [168].
Endotoxin is present in various organic dusts (particles of vegetable, animal and
microbial origin) and is a common pollutant in indoor domestic and work environments
where it can remain relatively stable. Castellan et al [174] showed that endotoxins can
maintain their original levels over a 6-year period in cotton dusts. The levels of environmental
endotoxin are evaluated using the Limulus amoebocyte lysate (LAL) assay or by gas
chromatography-mass spectrometry (GC-MS). The chromogenic modification of the LAL
assay although not internationally standardized, is an inexpensive, easy, accurate,
reproducible and sensitive option for the evaluation of endotoxin levels [164].
Exposure to endotoxin is widespread and its concentration is highly variable. Workers in
indoor occupational settings, such as manufacturing and agriculture, are a main concern due
to more intense exposure. High endotoxin concentrations can be found in cotton factories
(Shanghai: range 44-1,871 EU m-3, mean 366 EU m-3; 1 EU ≈ 0.1 ng [175]), cigarette
factories, fiberglass production facilities and paper mills, among other locations. In the
agricultural industry mean overall concentrations of 230 EU m-3 have been reported [176].
However, mean values of 2,700 and 1,190 EU m-3 were described, respectively, in primary
grain, seed and legume production sectors (96-42,300 EU m-3) and in the primary animal
production sector (62-8,120 EU m-3) [176]. Exposure also occurs in less dusty environments,
such as homes (<1 ng m-3 [177]), office buildings and libraries via contaminated ventilation
and humidifier systems [164, 165]. As individuals spend the majority of their time in indoor
environments and because indoor exposure to endotoxin can be potentially detrimental to
respiratory health, less-studied environments, such as domestic dwellings [178], schools
[179], day-care centers [180], airplanes [181] and even automobiles [182] are being
evaluated.
CONCLUSION
International regulation that normalizes indoor air quality is still lacking, particularly in
the European Union. This is mainly due to the absence of standardized protocols for
biocontaminants sampling and its laboratory analysis. Regardless of the type of public facility
(schools, hospitals, museums, libraries, and churches), the most frequent and dominant fungal
spores present in the indoor environment are usually the same and are highly influenced by
outdoor air. Occasionally, specific indoor sources may play an important role in spore
composition and air concentrations. There is a widely held consensus that methodologies
employed for air quality testing must be improved as thresholds for indoor microbes
concentrations capable of inducing diseases need to be established. Also, studies on the
relationships between specific fungi and bacteria and their impacts on human health remain
scarce. There is a huge microbial diversity still unrevealed in indoor air and this fact limits
several conclusions. Moreover, it is also urgent to understand the presence and transmission
mechanisms of several microbial agents in protected clinical environments to improve the
health and well being of patients, especially those subjected to immunosuppressive treatments
and longer stays at hospitals. We are sure that exciting times are ahead for this topic. Future
metagenomic studies will reveal additional microbes that could critically influence indoor
safety.
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Chapter

AIRBORNE FUNGI AND BACTERIA IN PUBLIC INDOOR

Manuela Oliveira1, Olga Maria Lage2 and Ricardo Araujo1

2.1. Indoor Air Quality: Guidelines

2.2. Mechanisms of Release, Dispersal and Deposition of Fungal Spores

Table 1. Recommendations for indoor fungal spore concentrations in public indoor

Meteorological elements such as temperature, relative humidity, and rainfall, influence

2.3.3. Museums and Libraries

2.3.4. Monasteries and churches

2.4. Health effects

2.4.1.1. Mechanisms of Allergy

synthesized by several species of Aspergillus, Byssochlamys and Penicillium, is a common

3.1. Indoor Concentrations and Diversity of Airborne Bacteria

Additionally, Angenent et al [122] found a noteworthy abundance of Mycobacterium avium

3.2. Mycobacterium tuberculosis

TB is caused by bacteria of the genus Mycobacterium, which are non-motile, slow

3.3. Legionella pneumophila

Prevention of legionellosis can be achieved through adequate measures to monitor,

3.4. Airborne Endotoxins

Gram-negative bacteria possess complex cell walls composed of a peptidoglycan layer

[5] ACGIH. Air sampling instruments for evaluation of atmospheric contaminants

[21] Santilli, J; Rockwell, W. Fungal contamination of elementary schools: a new

Influence of internal and outdoor factors on filamentous fungal flora in hematology

[92] Menotti, J; Waller, J; Meunier, O; Letscher-Bru, V; Herbrecht, R; Candolfi, E.

[125] Bouillard, L; Michel, O; Dramaix, M; Devleeschouwer, M. Bacterial contamination of

[156] Bornstein, N; Vieilly, C; Nowicki, M; Paucod, J; Fleurette, J. Epidemiological evidence

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