Frequently Asked Questions

The Mould Awareness Council is a non-profit organisation…

We discuss the health effects of inhaled biotoxins from WDBs on our health and also the impact of water damage to our buildings where we live and work and in public buildings.

The British English spelling is mould and is the one used throughout this FAQ. American English spelling omits the u.

MAC uses the term Mould Illness as an umbrella term to cover three types of conditions caused by mould, bacteria and their toxins, and other toxicants from water-damaged buildings.

1. Chronic Inflammatory Response Syndrome (CIRS): Sometimes referred to as biotoxin illness this subtype views mould/bacteria and other inflammagens/toxicants inhaled from water-damaged buildings as being able to cause a multisystem multi-symptom illness due to upregulation of the innate immune system and corresponding inflammatory cascade. This results in lowered regulatory hormones (α-MSH, VIP), increased inflammatory cytokines (C4a, TGF-β1, MMP-9, Leptin), dysregulated gene expression, and atrophy and/or inflammation in the brain. For a detailed overview of CIRS see CIRS Explained and for a detailed symptom list see Symptoms of CIRS. CIRS can also be caused by biotoxins from Lyme disease (Borrelia) and Babesia infection, or exposure to contaminated bodies of water (dinoflagellates/pfiesteria, cynobacteria from blue-green algae blooms) and ingestion of contaminated reef fish (ciguatera).
2. Fungal colonisation: This subtype views mould and yeast as a problem when found growing in, or on, the body, either in the gastrointestinal tract, nasal and/or sinus cavities, skin, lungs, and/or occasionally bloodstream. Culture tests (sinus, nasopharynx, lungs), organic acids testing, and stool testing can be used in diagnosis. Symptoms may be single system (localised to the system of colonisation), or, if the fungus is producing mycotoxins, multisystem. Fungal colonisation may be the underlying cause of subtype #1 or #3. Treatment usually involves antimicrobials to reduce the fungal burden and pro/pre-biotics to improve the terrain, but binding and inflammation reduction therapies are often used also.
3. Mycotoxin toxicity (Mycotoxicosis): For this subtype it is the mycotoxins produced by fungi causing a toxicity in the body, whether inhaled or produced by internal fungal colonisation, that is seen as the main issue. Symptoms can be similar to subtypes #1 and #2 although sometimes less severe. Diagnosis can involve urinary mycotoxin, or serum mycotoxin antibodies, although tests from #1 and #2 may also be positive. Mycotoxin toxicity can also cause secondary conditions such as autoimmunity or cancer.

Note: A person may have one or more of the above conditions concurrently.

1. Ritchie Shoemaker, MD (CIRS/Shoemaker Protocol)
   • Dr Shoemaker from Pocomoke City, Maryland in the USA is the leader for the CIRS subtype of Mould Illness, having discovered biotoxin illness in the late 1990s due to a pfiesteria outbreak on the Chesapeake Bay. By happenstance he found that giving cholestyramine for secretory diarrhea in patient resolved all symptoms. In the early 2000s he published studies showing that biotoxins from water-damaged buildings (then called sick building syndrome) caused a similar type of syndrome, that he later labelled CIRS-WDB.
2. Neil Nathan, MD/Jill Crista, ND
   • Drs Nathan and Crista mostly align with the fungal colonisation and mycotoxin toxicity subtypes of Mould Illness, acknowledging that these subtypes can cause chronic inflammation as well. They primarily use urinary mycotoxin testing for diagnosis and treatment involves targeted binders based on which mycotoxins are elevated. If fungal colonisation is suspected they also use pharmaceutical or herbal/natural antifungals orally and/or intranasally.
3. Andrew Campbell, MD
   1. Dr Campbell also aligns with the fungal colonisation and mycotoxin toxicity subtypes of Mould Illness. His preferred testing is serum mycotoxin antibodies done via the laboratory MyMycoLab, which he is the medical director of. His treatment protocol does not use binders, instead he uses the pharmaceutical antifungal itraconazole orally, and various supplements such as vitamin D and B complex, Omega 3s, CoQ10, melatonin and spore-based probiotics.

For fungal colonisation and mycotoxin toxicity, yes mould or yeast, or their byproducts (mycotoxins) are the cause.

However CIRS is caused by the toxigenic microbial soup found in water-damaged buildings and includes mould fragments, mycotoxins, mannans and beta-glucans from mould, endotoxins and exotoxins from bacteria (including gram positive and gram negative bacteria, mycobacteria and actinobacteria), microbial volatile organic compounds (mVOCs) from bacteria and mould, VOCs from building materials that are broken down through microbial activity, and many more compounds. Mould is just the most visible, most researched and easiest microbe to test for.

These are generally considered the mainstream medical viewpoints on how mould/fungi/yeast affect human health, and are not the main focus of MAC.

1. Mould allergy:  Usually seen as inhaled mould causing an allergic response in the upper respiratory system, causing asthma and/or rhinitis.  Doctors will usually test for mould allergy via IgE blood tests or skin prick tests. Treatment is centred on exposure reduction and/or immunotherapy.
2. Candidiasis
   1. An overgrowth of the yeast Candida. It can affect the skin, mouth, throat, vagina, and joints. Invasive candidiasis occurs when Candida spreads to the bloodstream creating a more serious illness.
3. Fungal infection (Mycosis): Invasive fungal infection of the blood or organs. Subtypes include:
   1. Tinea: Fungal infection of the skin that causes itching and rashes. Usually treated by topical antifungals.
   2. Aspergilloma/cryptococcosis: This is when the mould Aspergillus (or the yeast Cryptococcus) causes fungal balls in the lungs. Symptoms include a cough bringing up blood, wheezing, shortness of breath, weight loss and fatigue.
   3. Invasive aspergillosis/cryptococcosis: When the fungal infection from #2 spreads to the brain, heart, kidneys or skin, usually in people with weakened immune systems such as those having cancer chemotherapy/other immune suppressant drugs, bone marrow transplantation, HIV,  or other diseases of the immune system. Usually serious and, if untreated, can be fatal.
   4. Fungal meningitis: Similar to #3, but the fungus/yeast spreads to the areas around the central nervous system (e.g. brain or spinal cord).

Common conditions that Mould Illness is the causal factor of, a co-factor of, or co-morbid with, include

• Lyme disease (Borrelia), Bartonella, Babesia and other tick-borne or stealth infections (webinar)
• Myalgic Encephalomyelitis/Chronic Fatigue Syndrome (ME/CFS)
• Fibromyalgia
• Multiple Chemical Sensitivity (MCS)
• Inflammatory Bowel Disease (IBD), Irritable Bowel Syndrome (IBS), SIBO, Leaky Gut (webinar)
• Alzheimer’s Disease (webinar)
• Mast Cell Activation Syndrome (MCAS) (webinar)
• Multiple Sclerosis (MS)
• Depression
• Post Traumatic Stress Disorder (PTSD)
• Allergies

(ref: common misdiagnoses at Surviving Mold).

The VCS is a simple visual test available as a handheld version at a doctor’s office or online via the Surviving Mold website. It can be used to screen patients to see if they are affected by biotoxins/toxicants, as these cause inflammation that results in hypoperfusion (lack of blood flow) throughout the optic nerve.

The cost is US$15 although there are discounts for bulk purchasing which are handy if continue with the CIRS protocol.

Dr Shoemaker’s original research showed a sensitivity of 92.5% with only 7.5% false negative results, although this was done with a handheld device. False positive were even less (2.5%) and mainly seen in those who had been exposed to occupational solvents, heavy metals, hydrocarbons and petrochemicals.

If you are negative, you should go onto other screening and diagnostic testing to confirm or rule CIRS out but you may still be able to rely on VCS to track treatment.

Is there a free one available?

Yes, there is a freemium version available at VCSTest.com however the results don’t seem to correlate with the handheld or Surviving Mold versions. It’s strongly suggested to do both online tests if access to the handheld version is not available.

BIOMARKER	AUS LAB (NATA)	MEDICARE	FASTING	RANGE (Shoemaker)	NOTES
α-MSH	N/A			35-81 pg/mL
ACTH	Local lab	Y			Interpret with cortisol
Anti-gliadin antibodies	Local lab	Y		0-19 (IgA, IgM)	Sometimes elevated in CIRS
Anti-phospholipid antibodies	Local lab	Y		0-12 (IgA), 0-10 (IgG), 0-9 (IgM)	Sometimes elevated in CIRS
C4a	N/A			0-2830 ng/mL
Copectin (ADH surrogate marker)	Local lab -> RPA	N - Out of pocket cost varies		1.0-13.3 pg/mL	NSW Health Pathology page | Common pattern is low copeptin with high osmolality
Cortisol (AM)	Local lab	Y			Pattern can be low ACTH and low cortisol but sometimes high ACTH, high cortisol
DHEA	Local lab	Y			Sometimes low in CIRS
Estradiol	Local lab	Y			Sometimes high in CIRS
HLA DR/DQ	Sonic Group or NutriPATH	Y (66695)			Sonic page
Leptin	Local lab -> RPA	N - Out of pocket cost varies	Y	NR 2-5.6 ng/mL (M), 3.7-11.1 ng/mL (F)	NSW Health Pathology page
MMP-9	N/A			85-332 ng/mL
Serum Osmolality	Local lab	Y		280-300 mmol/kg	Interpret with ADH
Testosterone	Local lab	Y			Sometimes low in CIRS
TGF-β1	N/A			344-2380 pg/mL
VEGF	Local lab -> Peter MacCallum Cancer Centre	N - Out of pocket cost varies		31-86 pg/mL	Transport on ice / store refrigerated | Only performed infrequently
VIP	Local lab -> RPA	Y (71151)	Y	6.8-18.6 pmol/L	NSW Health Pathology page

See the Medical Testing page for in-depth information.

NutriPATH’s biotoxin/mould blood panels or individual biomarkers, apart from HLA DR/DQ and MARCoNS, cannot be recommended at this time due to inaccuracies compared to US laboratories.

No other accurate Australian diagnostic testing for TGF-b1, C3a, C4a, MMP-9, and MSH currently available.

Ref: Mold Illness in Children webinar (35m) and Low Tox Life podcast episode 55.

2.4.1 What is the HLA DR/DQ Genetic Tests (a.k.a. Mould Genes)?

In unpublished research conducted by Dr Shoemaker of his 10,000 size patient population approximately 25% of the general population have Human Leukocyte Antigen (HLA) genes that are mould, Lyme or multi-susceptible (i.e. susceptible to toxins from mould/WDB, Lyme, and dinoflagellates). Dr Shoemaker’s hypothesis is that when these genes are primed (see 2.4.5) and a person is exposed to a high level of toxins/toxicants from water-damaged buildings the immune system does not make the appropriate antibodies to clear them, due to a defect in antigen presentation, which creates a state of chronic inflammation and upregulation of the innate immune system.

Note: The HLA genes merely indicate genetic susceptibility to CIRS and having them does not automatically mean you have/or will develop CIRS.

2.4.2 Getting the HLA gene test in Australia

Any GP can request “HLA DR-DQ typing” (NOT “HLA DR/DQ for Coeliac Disease”) but it must be performed at a Sonic Healthcare laboratory for the results to be formatted correctly.

It can be fully covered by Medicare if your doctor checks the bulk bill box. However whether to bulk bill this test or not is up to your doctor.

2.4.3 Interpreting the results

If your doctor is unable to interpret you can put your numbers into the Australian HLA-DR calculator.

2.4.4 Does 23andme show these HLA genes?

No. 23andme does not show all the HLA haplotypes and not in a format that correlates to Dr Shoemaker’s table.

2.4.5 My partner/child has HLA susceptible genes but they don’t get sick with exposure to water-damaged buildings, how come?

Dr Shoemaker found that HLA genes generally need to be primed by an inflammatory illness, or event, that causes a cytokine storm such as influenza, Coxsackie virus, Lyme disease, mononucleosis (Epstein Barr Virus/glandular fever) or ECHO virus infections, intense inflammatory lung responses and unusual conditions such as Kawasaki disease. (Berry, 2014, p14). In 2021 Shoemaker et al published a paper that a small cohort (n=21) of Post COVID Syndrome (a.k.a. Long COVID) patients shared proteomic (blood protein) similarities to CIRS patients.

However, if there is a great deal of inflammagens, biotoxins and toxicants in a water-damaged building that can be enough to prime the genes and cause CIRS by itself.

2.4.6 HLA susceptibility in other disease states

MAC staff has put together a Google spreadsheet that summarises many disease susceptibilities, and also disease protection, corresponding to Dr Shoemaker’s HLA haplotypes found in the scientific literature. Autoimmune immune conditions in particular are prevalent.

2.4.7 Section References

• Berry, Y. (2014). A physician’s guide to understanding & treating biotoxin illness. Surviving Mold.
• Shoemaker R, Lipsey R. (2006). Results of health screening and visual contrast testing. St. Bernard’s Parish, Louisiana. Surviving Mold. Full-text
• Shoemaker R., McMahon S, Heyman, A., Lark, D, van der Westhuizen, M., & Ryan, J. (2021).Treatable metabolic and inflammatory abnormalities in Post COVID Syndrome (PCS) define the transcriptomic basis for persistent symptoms: Lessons from CIRS. Medical research archives, 9(7). https://doi.org/10.18103/mra.v9i7.2493

NeuroQuant® (NQ) is a software program from Cortechs Labs that measures microscopic volumetric changes in defined areas of the brain from a magnetic resonance imaging (MRI) scan. Dr Shoemaker found microscopic interstitial oedema, a.k.a. neuroinflammation, and atrophy, a.k.a. neuronal loss, in brain areas in two small studies (2014, 2017) of CIRS patients.

It can also be a tool to track inflammatory and atrophic changes at baseline and throughout treatment. Dr Mary Ackerley believes the Triage Brain Atrophy Report (TBAR), that takes into account normal ranges for patient sex and age, is more accurate than the general morphology report alone.

Multiple Antibiotic Resistant Coagulase Negative Staphylococci (MARCoNS) are bacteria that colonise the nasopharynx area forming biofilms and creating exotoxins. These form due to low levels of MSH in mucous membranes which is antimicrobial and anti-inflammatory. MARCoNS can themselves further lower MSH. Dr Shoemaker sees MARCoNS colonisation in 80% of CIRS patients. See the Biotoxin pathway diagram to see how hormones and immunity are affected in CIRS.

• Obtaining the collection tube
  1. Direct from Microbiology Dx
     Order swab kit from Microbiology Dx free of charge. Go to the ‘Order Collection Kits’ page and fill in the details. You’ll need to put Australia onto the ‘City, State, Zip’ field. You will need to include your doctor’s details on the web form. Ideally email them and ask for the Remel® BactiSwab™ wire shaft transport swab – although the default swab will suffice.
     Alternatively you can use an aerobic nasal swab from your doctor and get your doctor to fill out the requisition form.
  2. NutriPATH
     Order a kit via NutriPATH, who send it on to Microbiology Dx.
• Performing the swab

• • This can be done by a doctor or patient. The swab needs to go through the nose right up to the back of the throat, about 3 inches. Swivel the swab for 3-5 seconds when you reach the throat. It is unpleasant but not painful. Read the Microbiology Dx instructions or read the blog post on Biotoxin Journey for directions.

• Sending swab to Microbiology Dx

• • When used with the correct swab, the sample is viable for up to 30 days. There are several options for sending it to Microbiology Dx. Write “non-infectious sample” on the customs form.
    1. Australia Post air mail letter. The cheapest option.
    2. Australia Post’s EMS Courier.
    3. FedEx. Supplied with the kit from Microbiology Dx.

• Sending swab to NutriPATH

• • Follow the instructions in the NutriPATH kit.

• Cost

• • Currently the cost for MARCoNS and other bacteria with sensitivities is US$85. The results will be emailed to your doctor. NutriPATH is more expensive (AU$150).

• Fungal culture testing

• • This is available at an additional cost (US$80) and takes longer to report than MARCoNS.

• Biofilm testing

• • This is optional (US$100) but can be useful as it tells you if any biofilm is present and at what strength. Dr Shoemaker originally deduced that MARCoNS produced biofilm when they were resistant to 2 or more antibiotic classes but this may not always be the case.

• Interpretation

• • If the culture reveals coagulase negative staph which are resistant to two or more antibiotics then you are positive for MARCoNS and should be treated with a suitable nasal spray (see 5.2 MARCoNS Treatment). The amount (“large amount” etc.) is not important. If the culture is methicillin resistant you may herx more when using anti-microbials. Staph coag positive (golden staph), staph coag neg with only one antibiotic resistance, non-staph bacteria are common findings and do not need to be treated generally.

Two laboratories, Realtime (available via NutriPATH) and Mosaic (formally Great Plains, available via RN Labs) currently offer urine mycotoxin testing in Australia.

Realtime in their Mycotoxin panel use enzyme-linked immunosorbent assay (ELISA) technology while Mosaic in their MycoTOX profile use liquid chromatography tandem mass spectrometry (LC-MS/MS) technology.

See the Medical Testing page for more details, including research studies, on both of these tests.

Dr Shoemaker does not recommend these tests for a number of reasons:

1. Mycotoxins make up < 10% of the burden of inflammagens in a WDB.
2. These tests only look for one to two dozen mycotoxins when there have been four hundred discovered so far.
3. These tests are polyclonal and have never had specificity of their antibodies confirmed (Realtime test).
4. Urine mycotoxins are generally confounded by mycotoxin ingestion from common foods such as grains, corn, peanuts, tree nuts, chocolate and coffee.

See Dr Shoemaker 2015's Hopkinton Lecture (2:24:53. Thoughts on Realtime Labs) and Dr Joseph Brewer: Nasal fungi, anti-fungals and junk science.

Physician and researcher Dr Andrew Campbell believes mycotoxin antibodies in the blood are the best measure of the toxic burden from mould exposure.

His company MyMycolab provides testing of IgG and IgE antibodies of 12 different types of mycotoxins in blood serum. He believes the IgE response occurs when there is a large exposure to that particular mycotoxin, and has mast cell involvement, while IgG responses are indicative of lesser amounts of exposure. Unlike antibodies to mould spores mycotoxin antibodies are short lived and should reduce after 6 months of avoiding exposure.

Testing (USD $380) can be ordered and drawn by those in Australia and shipped back via FedEx.

See the Medical Testing page for more details, including research studies, on this test.

Mould allergy testing tests for an IgE allergic reaction to certain species of mould spores, usually a mould mix, and not mycotoxins. This is usually done via skin prick testing or blood RAST testing. This is a common test offered by most laboratories, covered by Medicare, and often the only mould-related test most GPs or allergists will know of and worth doing.

As stated previously mould allergy is an adaptive immune system antibody response and is different from CIRS which is a chronic innate immune system response. It is possible, but not that common, to have both mould allergy and CIRS.

ArminLabs in Germany, known for their Lyme (Borrelia) and co-infection testing also offer EliSpot testing for Aspergillus Peptide Mix 1 & 2. This tests for the cell-mediated, rather than the humoral (antibody), arm of the adaptive immune system.

Reducing or, ideally, eliminating exposure to mould and other biotoxins/toxicants from water-damaged buildings is the first step in any treatment protocol for any kind of mould-related illness. Before spending money on any other form of treatment, patients need to avoid the source of their illness. While this step is of paramount importance, it is often the most difficult, because places of residence (home), work, education (school, university), and even vehicles all need to be considered. These locations and vehicles will need to be either adequately remediated (which can be costly), or the patient will need to relocate to a safer environment or replace the vehicle.

Many Mould Illness patients develop an environmental sensitivity, whereby they react to even small amounts of biotoxins and toxicants in water-damaged buildings and vehicles. Some of the most extreme reactors often resort to camping in dry locations in tents, caravans (RVs), or converted trailers. Patients monitor how their symptoms fluctuate to deduce what locations or (potentially) even possessions are exacerbating their illness.

This form of extreme mould avoidance originated with Erik Johnson, who was a prototype for chronic fatigue syndrome during the original outbreak of the syndrome around Lake Tahoe, Nevada in the mid-1980s. Erik became largely symptom free with using extreme mould avoidance. For more on Erik’s story and mould-avoidance techniques, please read Back from the edge by Lisa Petrison (see resources).

The use of binding medications or supplements to adsorb mycotoxins and other toxins/toxicants in the intestines is suggested by most Mould Illness practitioners, except for Dr Andrew Campbell and those strictly following his protocol.

Side-effects

Binders can have some gastrointestinal (GI) side-effects such as constipation, gas, and acid reflux. Constipation can usually be ameliorated with magnesium citrate, vitamin C, and/or soluble fibre (chia seeds, flax seeds, and psyllium). Long-term use of binders can deplete fat soluble vitamins (A, E, D, K, CoQ10), so many practitioners suggest to supplement these, taking them at a different time of day to binder dosing.

How long do I stay on binders?

This is highly individualised but typically varies between three and twelve months. Duration of binder use is dependent on improvement in lab work, symptom reduction, and absence of exposure to further water-damaged buildings.

Some people stay on a lower maintenance dose of binders on a continual basis, or increase them short term when re-exposed to a water-damaged building (e.g., take a full dose for 3–7 days after exposure).

Worsening of symptoms (intensification reaction)

Dr Shoemaker hypothesised that binders, especially cholestyramine, can cause an intensification reaction (a general worsening of symptoms)—commonly but incorrectly referred to as herxing/herx—especially in Lyme patients. This is because as biotoxins detach from cell receptors, they can enter the bloodstream and cause a rise in inflammatory cytokines.

Symptoms will generally be exacerbated, along with a worsening of visual contrast sensitivity (in columns D and E). The protein biomarker MMP-9 will also increase.

Dr Shoemaker suggests an inflammatory-lowering mini-protocol using fish oil. Start at least ten days before starting cholestyramine. If symptoms intensify, either lower or stop the cholestyramine dose, and then follow the interventions below for 5–10 days before restarting.

• No-amylose diet:
  • A no-amylose diet enhances the effectiveness of Actos or fish oil.
    Amylose is found in most grains, vegetables grown below the ground (root vegetables), and bananas. Similar diets include low carbohydrate, grain free, paleo diets such as the Bulletproof diet, Wahls Diet, or Doug Kaufman’s Phase I diet for at least the duration of CSM treatment.
• High-dose fish oil:
  • High-dose fish oil can lower inflammatory cytokines and other inflammatory markers. Dr Shoemaker suggests a dose of fish oil where the daily total of EPA at least 2.4 grams per day and DHA is 1.8 grams for ten days, with cholestyramine started on day six. Many people stay on this high-dose fish oil for longer.

Two pharmaceutical binders are available by presciption only.

Cholestyramine (CSM)

Cholestyramine (CSM) is a sixty-year-old cholesterol lowering medication that has been extensively studied with a good safety profile. This negatively charged binding resin attracts positively charged toxins/toxicants from bile and excretes them in the faeces. It is not absorbed systemically but only passes through the gastrointestinal tract. CSM is available in Australia either as Questran Lite, which contains aspartame, or as a pure compounded version. The compounded version may contain stevia and various forms of cellulose, which are harmless excipients for most people. (See resources for compounding pharmacies.) The full dosage is four grams four times per day (QID), thirty minutes before meals/medications or one-two hours after meals/medications. Many clinicians suggest starting with a small dose (1–4 grams) and working your way up to the full dose.

CSM is the only binder tested in clinical trials in humans that demonstrates efficacy in lowering associated inflammatory biomarkers.

Colesevelam (Welchol)

Colesevelam (brand name Welchol) is a medication similar to CSM. It generally causes less GI side effects, and can be taken with food. It is the binder recommended by Dr. Shoemaker for sensitive patients who can’t tolerate CSM. One caveat is that colesevelam only has 25% of the binding capacity of CSM. Like CSM, colesevelam can only be obtained at a select number of compounding pharmacies in Australia. Dosage is two tablets (625mg) up to three times per day.

Non-systemic binders (these stay in the GI tract)

• Activated charcoal—A broad spectrum binder that has been used successfully in animal mycotoxin and endotoxin (bacterial toxin) studies. It can also bind pesticides and VOCs but may bind with nutrients so, as with CSM, activated charcoal is best taken away from other supplements and medications. Suggested dose: 500–1000mg, 2–4 times per day. Suggested brands: Bulletproof, Blants (powder form) and Nature’s Way. Caveat: it will cause darkening of stools.
• Chitosan—Similar in structure to CSM and Welchol, Chitosan has a similar effect to those medications of lowering cholesterol, but it may also have anti-microbial and anti-cancer properties. Caveat: Derived from shellfish. (1, 2, 3). Suggested dose: 500–1000mg, 2–4 times per day. Suggested brands: Now, Nutricology, and Natural Balance.
• Bentonite clay (aka montmorillonite)—Binds to mycotoxins (1, 2), bacterial toxins (1, 3), pesticides (1), and heavy metals (1). Suggested dose: 1–3 grams, 2–4 times per day. Suggested brands: Blants, also widely found on eBay (make sure it is marked for human consumption/internal use).
• Zeolite clay (aka clinoptilolite)—Similar to bentonite clay. Established as a mycotoxin binder in animal studies (1, 2, 3). Suggested dose: as per bentonite. Suggested brands: Vita Pure (LavaeVitae), Zeolith MED, Toxaprevent, ZeoBind (BioPure)

Systemic (these are absorbed into the blood stream)

• Nanoised zeolite—This is a form of  zeolite small enough to be absorbed into the blood stream and cells from the gut. As with normal zeolite, it is mainly thought of as a heavy metal chelator. (No peer reviewed studies are found for nanoised zeolite and chelation or binding; refer to zeolite research above.)
• Modified citrus pectin—A fibre from citrus peel that is known to bind to heavy metals (especially lead) and environmental toxins. It also has anti-cancer/anti-galectin 3 effects. Brands include Pectasol-C and Now (among others). (1, 2, 3, 4).
• Glutathione—The body’s master antioxidant. It can also aid in the detoxification of toxins including mycotoxins, and heavy metals. Gluthathione can be used in various forms including liposomal, intravenous, intranasal, N-acetylcysteine (a precursor) and L-glutathione.

Combination formulas

• Ultra Binder (Quicksilver Scientific)—This formulation combines bentonite clay, activated charcoal, chitosan, aloe vera, zerolite, and acacia gum.

• Shoemaker, R. C., & House, D. E. (2006). Sick building syndrome (SBS) and exposure to water-damaged buildings: time series study, clinical trial and mechanisms. Neurotoxicology and teratology, 28(5), 573-588. PMID 17010568
• Shade et al. (2018). A Push-Catch System That Enables Effective Detoxification. The Townsend letter, February/March 2018. Link.
• Huwig, A., Freimund, S., Käppeli, O., & Dutler, H. (2001).  Mycotoxin detoxication of animal feed by different adsorbents. Toxicol Lett, 122(2):179-88. PMID 11439224
• Wilson, T. (2017). Are you detoxing with the correct binders. Sophia Health Institute. Link.
• Rudd, C. (2024). The Binder Compendium. Google doc.

A popular treatment protocol for Mould Illness (CIRS) is the Shoemaker Protocol, named after its originator, researcher Dr Ritchie Shoemaker. This is an eleven-step protocol designed to restore immune homeostasis. Parts, but not all, of this protocol have been trialled in published studies on CIRS, unlike some other Mould Illness protocols.

According to the Shoemaker Protocol, after removal from mould exposure/WDBs and at least one month of binders, MARCoNS should be treated if tested positive.

• Current Recommended Treatment—EDTA plus colloidal silver nasal spray
  • If positive for MARCoNS, a patient will be begin a nasal spray of EDTA/colloidal silver nasal. EDTA helps break down the biofilm and the colloidal silver is an effective antimicrobial with some anti-biofilm activity as well. The duration of this treatment can be between one and several months.
• Past Treatments
  • Previously, BEG nasal spray was used which contained Bactroban, EDTA, and Gentamicin. With the increase of antibiotic resistant MARCoNS strains and studies done by Dr Joseph Musto of Microbiology DX showing the effectiveness of colloidal silver, the protocol has been changed.
• Alternative treatments
  • Neti pot or nasal spray of water with iodine or salt or xylitol (e.g. xyclear).
  • Colloidal silver nasal spray by itself may help.
  • Nebulised PVP-iodine may be effective according to Greg Muske of Biotoxin Journey. Read his detailed MARCoNS, More MARCoNS, and Even more MARCoNS blog posts for more details.
• Follow up testing
  • After one to several months of treatment, patiensts should repeat the MARCoNS test. If still positive, consult with your health practitioner for treatment options.

After removal from WDB exposure, pharmaceutical binders, and treatment of MARCoNS, patients will undertake a number of mid-level steps aimed at both reducing inflammatory biomarkers and restoring affected hormones to normative levels.

Vasoactive Intestinal Polypeptide (VIP) is a neuropeptide hormone that is predominately made in the hypothalamus. Along with MSH, VIP is critical in controlling inflammation and the immune system. In a 2013 study and in clinical practice, Dr Shoemaker found that VIP:

• Increased plasma VIP levels
• Reduced symptoms to the level of healthy controls
• Reduced inflammatory cytokines (TGF-b1, C4a, MMP-9)
• Increased VEGF
• Balanced Treg immunity
• Increased 25-Vitamin D levels
• Normalised low testosterone levels in Males
• Normalised high estradiol (estrogen) levels in Males
• Increased tolerance to water-damaged buildings

Intranasal VIP has also been shown in a small clinical trial and case studies to correct multinuclear atrophy of grey matter in the brain, although further research is needed to confirm these findings.

However, the caveat to VIP therapy is that if you’re still being exposed to biotoxins from water damaged buildings or MARCoNS,  then instead of reducing inflammation—such as TGF-b1 and C4a—VIP can potentially increase it. Thus, the following conditions must be met before using VIP spray.

• You live, work, and study in buildings with a HERTSMI-2 score of < 11
• You pass the VCS test
• You test negative for MARCoNS
• You have normal lipase levels.

My VIP level is normal, can I still benefit from VIP spray?

Yes. VIP has wide ranging effects apart from repleting VIP plasma levels. If you still have symptoms even with a normal VIP level, VIP may help.

For the fungal colonisation subtype the eradication or reduction of fungal and yeast colonies is usually recommended using herbal/natural and/or pharmaceutical antifungals. This may also involve biofilm eradication (biofilm busting) as these fungal/yeast colonies are often protected by biofilms.

Some protocols and doctors also aim to balance the nasal/sinus, oral, gut or skin microbiome(s) to improve a person’s external or internal microbiome terrain.

Removal from mycotoxin exposure is the the first step in the mycotoxin toxicity Mould Illness subtype. Either via removal from exposure to water-damaged buildings/vehicles and/or reduction of internal fungal colonisation.

Most practitioners, except for Dr Andrew Campbell, generally suggest that binding supplements/medications is then needed to bind (adsorb) mycotoxins in the GI tract after being released in the bile. See Part 4.3-4.5 above for more information on this.

Dr Shoemaker discourages the use of nasal antifungals for two main reasons:

1. The rates of fungal colonisation in the nasal passages in CIRS patients is the same as healthy controls
2. Anti-fungal use can cause antibiotic resistance to nasal bacteria such as MARCoNS as fungus and bacteria can transfer genes to one another.

See Dr. Joseph Brewer: Nasal fungi, anti-fungals and junk science.

There are several professions that inspect buildings for water damage and mould, who may also do sampling for mould/microbial growth including Building Biologists, ACAC certified inspectors, Mycologists/Microbiologists and Occupational (Industrial) Hygienists. The IICRC S520 Mold Remediation standard uses the umbrella term Indoor Environmental Professionals (IEPs) for these professions. These professionals are able identify the source and extent of water damage, moisture and, if necessary, amount and location of microbial growth via sampling. They can also determine the required scope of works to return the property to pre-event condition, and after remediation,  provide post-remediation verification. They may send mould samples to microbiologists or other laboratories for analysis and quantification.

Please see the Mould and Building Inspection page.

Yes, ideally. According to the IICRC S520 Standard for Professional Mold Remediation:

4.2.1 Assessment
When a preliminary determination indicates that mold contamination exists or is likely to exist, an assessment should be performed prior to starting remediation. An independent IEP who has no business affiliation with the remediator should be used for this purpose. In circumstances where an entire building or system is fully involved as a result of Condition 3 mold contamination or when the scope of work can be determined without sampling or independent IEP inspection and assessment, engagement of an IEP for assessment may not be necessary. Notwithstanding the foregoing, if health issues are discovered or apparent that seem to be related to the actual or suspected mold contamination, an IEP or other appropriate professional should be engaged by the property owner and the extent and Condition (1, 2 or 3) to which areas of the structure, systems and contents are potentially mold contaminated should be assessed, documented, and reported to the client.

Likewise according to the ACAC code of conduct:

Note on Conflicts of Interest:

The American Council for Accredited Certification strongly discourages its certificants from performing both assessment services and contracting services on the same project. Certificants who offer both services to the same client create a perceived conflict of interest regardless of their integrity. Nevertheless, as circumstances sometimes prevent the employment of multiple professionals on the same project, ACAC does not prohibit the practice, nor does ACAC make compliance with this policy a condition of continued certification.

MAC does not favor one group of professionals over another for the investigation and remediation of water damage and microbial growth in buildings. Neither can we personally vouch for any of the professionals on the Mould and Building Inspection page — do your own due diligence and research.

Yes, the international standard is the ANSI/IICRC S520 Standard for Professional Mold Remediation (Fourth edition, 2024).

Mould Illness/CIRS patients may need a higher level of remediation than the IICRC standard. The Surviving Mold protocol to achieve this level is outlined in Schrantz, et al. (2021).  Indoor Environmental Professional Panel of Surviving Mold Consensus Statement for Microbial Remediation 2020. Medical Research Archives, 9(1). https://doi.org/10.18103/mra.v9i1.2327

IICRC and ACAC also offer certifications in mould remediation.

Please see the Mould Remediators page.

Yes, ideally. See Part 7.3 of this FAQ.

Please see the Mould 101 – Preventing, Removing and Remediating page.