Your Home: Where the thought leaders stand on indoor air

Part 6, the penultimate instalment, in a series mapping the major thinkers in CIRS and mold-related illness. Across Parts 1 through 5 we asked where each camp locates the illness.

This post asks the question that sits underneath all of them: what about the environment?

Each of the camps we discussed quietly notes that in order to heal, you need to be in a mold-free environment. You can’t calm an immune system or bind a toxin if you keep breathing in the thing that’s making you sick. On this, remarkably, all four camps agree. I dare say we might even have consensus here.

Yet underneath that agreement sits a set of ambiguity that almost never gets voiced out loud:

How do you actually know a building is making someone sick?
How clean is clean enough?
How do you know a remediation worked?
What do you do with belongings that were in a water-damaged building?

In my practice, nearly every patient and my team spend months working on the indoor environment. This step is so incredibly important. I’d argue it is the most important step. No binders, peptides, nervous system work, detox routine, etc. is going to do a damn thing if you’re still inhaling biotoxins on a daily basis.

Even though the environment is so important, it’s hardly discussed between the thought leaders. It’s as though there’s a quiet assumption that of course you have to get out of mold. I don’t disagree. But we need some parameters on how to do this. Today’s post will help give you, dear reader, some insight on how to know your indoor air is in support or hinderance of your recovery.

Step 1: Removal from Exposure

Shoemaker makes removal from exposure the first step of the protocol. Nothing else proceeds until it’s addressed. Nathan and Crista preach mold avoidance as foundational. Campbell’s model, built on the immune reaction to the toxin, notes that healing will only occur when exposure is managed. Even Holtorf, whose whole framework de-emphasizes the toxin, agrees the exposure was the tipping point.

So if you take nothing else from this series: there is no version of mold-illness treatment, in any camp, where you stay in the water-damaged building and medicate your way out.

The disagreements begin the moment you ask how do you know you’re out of exposure.

Shoemaker’s Genius: How to Determine if a Home is Safe

The environment is the part of the field where Shoemaker is, frankly, in a class by himself.

Most of mold medicine treats “is the building safe?” as a question for a contractor, a home inspector, or an environmental professional. Shoemaker treats it as a clinical question. Meaning that he was less concerned about meeting building codes and far more concerned about how home environments correlated with human health. He was so dedicated to this cause that he actually built tools to measure how mold scores in a home affect recovery.

If you’ve ever hired a company to come and evaluate your home for mold, they undoubtedly would have used a technique known as air sampling with spore traps. If you have a positive test results from air sampling, you can know with confidence that there’s a mold problem. The concern is if the air sample comes back clean. A good number of mold spores settle in dust; they’re quite heavy so catching them in the air is unlikely.

But most damning to air sampling is the lack of sample size. Most air sampling devices are calibrated to sample 15L of air per minute. Samples are generally taken for 5 minutes. This equates to 75L of air sampled. Now, let’s measure a typical room in your home:

• Living room: 12ft x 15ft x 9ft ceilings = 76,400 L of air
• Small bedroom: 10ft x 10ft x 8ft ceilings = 22,600L of air
• Average room: 12ft x 12ft x 8ft ceilings = 32,600L of air

In a small room, we’re sampling 0.33% of the air. In a living room, we’re only sampling 0.1% of the air. And this you could feel profoundly unwell in a home that has an air sample that tested clean. I’ve seen exactly this: clean air report, high dust-DNA score, and bloodwork showing profound inflammation. The air test missed it.

Enter dust-based DNA testing.

The ERMI (Environmental Relative Moldiness Index), which quantifies 36 mold species by qPCR, and its streamlined cousin the HERTSMI-2, which focuses on the five species (“the Big 5”) most tied to health effects in water-damaged buildings and converts them into a simple score.

What makes the HERTSMI-2 more than just another test is that Shoemaker tied the numbers to patient outcomes. In a study of over 800 CIRS patients, a low HERTSMI-2 score (under 11) predicted safety from relapse for previously-sensitized patients with high accuracy, while high scores strongly predicted recrudescence. That gives both a remediation target and a re-entry decision rule: remediate to identify and fix every water source, remove damaged materials, clean thoroughly, then re-test. A HERTSMI-2 at or below the cutoff is your objective green light to re-occupy.

No other camp has anything like this. Where the others say “get the patient somewhere safe,” Shoemaker tells you how to measure safe, with a number validated against whether patients actually got sick again. For a sensitized patient deciding whether it’s safe to move back home, that’s the difference between a guess and a decision.

The Science on Home Testing is not Settled

The dust-DNA approach has real limits and real critics.

Dust DNA is a sampling method, and sampling is imperfect.

• A dust sample captures what settled in one place over some window of time. It can miss a localized reservoir, get skewed by how and where the sample was taken, and vary with collection technique.
• A single low score is a data point, not a guarantee.

DNA doesn’t distinguish living from dead, or recent from old.

• qPCR detects genetic material whether or not the mold is currently active.

The cutoffs come from clinical observation, not regulatory consensus.

• The ERMI was developed by the EPA as a research tool, not a clearance standard, and the EPA does not endorse it for routine home diagnosis.
• The HERTSMI-2 thresholds that CIRS practitioners rely on come from Shoemaker’s own research. But it’s one investigator’s dataset, not an independently ratified building code. Reasonable building scientists argue about where the lines should sit.

Testing can be expensive and anxiety-producing in practice.

• Chasing a low score can drive costly repeat remediation and testing, and for an already-frightened patient it can tip into a kind of environmental hypervigilance that becomes its own problem.
• This methodology is excellent at assessing the historical biotoxin burden of a home. But it is not great at assessing levels immeidatly following a remediation or small particle cleaning.

The five molds found on the HERTSMI-2 report are not all of the pathogenic molds.

• I saw this yesterday in clinic: A patient with significant worsening of symptoms. A HERTSMI-2 score of 0. Significantly elevated TGF beta 1 and MMP9 blood tests; two biomarkers that suggest ongoing exposure.
• It was only after running an additional panel for 6 more pathogenic molds that we found significantly elevated levels of Penicillium Brevicompactum.
• If we relied soley on HERTSMI-2 testing, we would have missed this completely.

What this means for you:

Home testing is complicated. A HERTSMI-2 <11 or a clean air sample does not mean the indoor environment is clear. All of the tests are imprecise and have a margin of error. Use the testing as signposts but not an oracle.

What the other Camps do for Environment Testing

Nathan and Crista

You won’t find any pushback from these two that having a clean indoor air environment is essential to healing. My most recent readings of Dr. Crista’s work suggest that she is currently recommending Hayes Lab (https://hayesmicrobial.com/) for environmental testing. What this lab evaluates is mycotoxins; not the molds themselves, but the toxic metabolites produced by the molds. Sampling is done from surfaces. So it is not using air sampling methodology.

We run into the same problem here that we do with urinary mycotoxin testing… There are zero established thresholds. As of my writing, we don’t have control values of what is normal vs what is abnormal. And we certainly don’t have data to suggest that anything beyond “x” level is harmful to human health.

Campbell

I’ve not been able to find a ton of information on exactly how Dr. Campbell recommends testing the environment. Based off of interviews I seen of his, he cautions relying solely on either air sampling and ERMI testing. He seems to be a strong supporter of on-site investigations. When these occur, inspectors will generally come equipped with moisture meters and infrared cameras.

You’ll get no pushback from me in supporting onsite investigation. Infrared cameras and moisture meters are genuinely helpful tools for identifying active water damage. But the concern in CIRS treatment is often the molds we cannot see. It’s these insidious exposures that stall progress.

Holtorf

Holtorf is of the mind that the environment is less of a concern than your  immune system’s dysfunction. From the little I can gather online, he is of the mind that a low mold diet, sauna, and of course, peptides are the solution. I have not been able to identify any specific recommendations regarding the indoor environment outlined in his protocol.

What I take from all of this

The environment is the most important part of treatment. Full stop.

I don’t think anyone has thought through this aspect more than Dr. Shoemaker. And I still feel we have much to learn.

In my next post, I’ll discuss the methodologies I use for environmental testing and why I think it is the most thorough means of analysis at present.