Abridged version of the AWMF guideline for the medical clinical diagnostics of indoor mould exposure

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Abstract

This article is an abridged version of the AWMF mould guideline “Medical clinical diagnostics of indoor mould exposure” presented in April 2016 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine ( Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with the above-mentioned scientific medical societies, German and Austrian societies, medical associations and experts. Indoor mould growth is a potential health risk, even if a quantitative and/or causal relationship between the occurrence of individual mould species and health problems has yet to be established. Apart from allergic bronchopulmonary aspergillosis (ABPA) and mould-caused mycoses, only sufficient evidence for an association between moisture/mould damage and the following health effects has been established: allergic respiratory disease, asthma (manifestation, progression and exacerbation), allergic rhinitis, hypersensitivity pneumonitis (extrinsic allergic alveolitis), and increased likelihood of respiratory infections/bronchitis. In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitizing prevalence of 3–10% in the general population across Europe. Limited or suspected evidence for an association exist with respect to mucous membrane irritation and atopic eczema (manifestation, progression and exacerbation). Inadequate or insufficient evidence for an association exist for chronic obstructive pulmonary disease, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis and cancer. The risk of infection posed by moulds regularly occurring indoors is low for healthy persons; most species are in risk group 1 and a few in risk group 2 ( Aspergillus fumigatus, A. flavus) of the German Biological Agents Act ( Biostoffverordnung). Only moulds that are potentially able to form toxins can be triggers of toxic reactions. Whether or not toxin formation occurs in individual cases is determined by environmental and growth conditions, above all the substrate. In the case of indoor moisture/mould damage, everyone can be affected by odour effects and/or mood disorders. However, this is not a health hazard. Predisposing factors for odour effects can include genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for mood disorders may include environmental concerns, anxiety, condition, and attribution, as well as various diseases. Risk groups to be protected particularly with regard to an infection risk are persons on immunosuppression according to the classification of the German Commission for Hospital Hygiene and Infection Prevention ( Kommission für Krankenhaushygiene und Infektionsprävention, KRINKO) at the Robert Koch- Institute (RKI) and persons with cystic fibrosis (mucoviscidosis); with regard to an allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma should be protected.

The rational diagnostics include the medical history, physical examination, and conventional allergy diagnostics including provocation tests if necessary; sometimes cellular test systems are indicated. In the case of mould infections the reader is referred to the AWMF guideline “Diagnosis and Therapy of Invasive Aspergillus Infections”. With regard to mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medicine standpoint it is important that indoor mould infestation in relevant dimension cannot be tolerated for precautionary reasons. With regard to evaluating the extent of damage and selecting a remedial procedure, the reader is referred to the revised version of the mould guideline issued by the German Federal Environment Agency ( Umweltbundesamt, UBA).

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EPOS 2012: European position paper on rhinosinusitis and nasal polyps 2012. A summary for otorhinolaryngologists

W.J. Fokkens, V.J. Lund, J Mullol … (2012)

The European Position Paper on Rhinosinusitis and Nasal Polyps 2012 is the update of similar evidence based position papers published in 2005 and 2007. The document contains chapters on definitions and classification, we now also proposed definitions for difficult to treat rhinosinusitis, control of disease and better definitions for rhinosinusitis in children. More emphasis is placed on the diagnosis and treatment of acute rhinosinusitis. Throughout the document the terms chronic rhinosinusitis without nasal polyps (CRSsNP) and chronic rhinosinusitis with nasal polyps (CRSwNP) are used to further point out differences in pathophysiology and treatment of these two entities. There are extensive chapters on epidemiology and predisposing factors, inflammatory mechanisms, (differential) diagnosis of facial pain, genetics, cystic fibrosis, aspirin exacerbated respiratory disease, immunodeficiencies, allergic fungal rhinosinusitis and the relationship between upper and lower airways. The chapters on paediatric acute and chronic rhinosinusitis are totally rewritten. Last but not least all available evidence for management of acute rhinosinusitis and chronic rhinosinusitis with or without nasal polyps in adults and children is analyzed and presented and management schemes based on the evidence are proposed. This executive summary for otorhinolaryngologists focuses on the most important changes and issues for otorhinolaryngologists. The full document can be downloaded for free on the website of this journal: http://www.rhinologyjournal.com.

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Aspergillus fumigatus is one of the most ubiquitous of the airborne saprophytic fungi. Humans and animals constantly inhale numerous conidia of this fungus. The conidia are normally eliminated in the immunocompetent host by innate immune mechanisms, and aspergilloma and allergic bronchopulmonary aspergillosis, uncommon clinical syndromes, are the only infections observed in such hosts. Thus, A. fumigatus was considered for years to be a weak pathogen. With increases in the number of immunosuppressed patients, however, there has been a dramatic increase in severe and usually fatal invasive aspergillosis, now the most common mold infection worldwide. In this review, the focus is on the biology of A. fumigatus and the diseases it causes. Included are discussions of (i) genomic and molecular characterization of the organism, (ii) clinical and laboratory methods available for the diagnosis of aspergillosis in immunocompetent and immunocompromised hosts, (iii) identification of host and fungal factors that play a role in the establishment of the fungus in vivo, and (iv) problems associated with antifungal therapy.

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Respiratory and Allergic Health Effects of Dampness, Mold, and Dampness-Related Agents: A Review of the Epidemiologic Evidence

Mark J. Mendell, Anna Mirer, Kerry KW Cheung … (2011)

Objectives Many studies have shown consistent associations between evident indoor dampness or mold and respiratory or allergic health effects, but causal links remain unclear. Findings on measured microbiologic factors have received little review. We conducted an updated, comprehensive review on these topics. Data sources We reviewed eligible peer-reviewed epidemiologic studies or quantitative meta-analyses, up to late 2009, on dampness, mold, or other microbiologic agents and respiratory or allergic effects. Data extraction We evaluated evidence for causation or association between qualitative/subjective assessments of dampness or mold (considered together) and specific health outcomes. We separately considered evidence for associations between specific quantitative measurements of microbiologic factors and each health outcome. Data synthesis Evidence from epidemiologic studies and meta-analyses showed indoor dampness or mold to be associated consistently with increased asthma development and exacerbation, current and ever diagnosis of asthma, dyspnea, wheeze, cough, respiratory infections, bronchitis, allergic rhinitis, eczema, and upper respiratory tract symptoms. Associations were found in allergic and nonallergic individuals. Evidence strongly suggested causation of asthma exacerbation in children. Suggestive evidence was available for only a few specific measured microbiologic factors and was in part equivocal, suggesting both adverse and protective associations with health. Conclusions Evident dampness or mold had consistent positive associations with multiple allergic and respiratory effects. Measured microbiologic agents in dust had limited suggestive associations, including both positive and negative associations for some agents. Thus, prevention and remediation of indoor dampness and mold are likely to reduce health risks, but current evidence does not support measuring specific indoor microbiologic factors to guide health-protective actions.

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Author and article information

Contributors

Gerhard A. Wiesmüller: gerhard.wiesmueller@stadt-koeln.de

Journal

Journal ID (nlm-ta): Allergo J Int

Journal ID (iso-abbrev): Allergo J Int

Title: Allergo Journal International

Publisher: Springer Medizin (Munich )

ISSN (Electronic): 2197-0378

Publication date (Electronic): 28 February 2017

Publication date PMC-release: 28 February 2017

Publication date (Print): 2017

Volume: 26

Issue: 5

Pages: 168-193

Affiliations

[1 ]ISNI 0000 0001 0728 696X, GRID grid.1957.a, Institute for Occupational Medicine and Social Medicine, University Hospital, Medical Faculty, , RWTH Aachen University, ; Aachen, Germany

[2 ]Department of Infection Control and Environmental Hygiene, Cologne Health Authority, Neumarkt 15–21, 50667 Cologne, Germany

[3 ]Formerly: Regional Social Security Authorities (LAsD) for Schleswig-Holstein, Kiel, Germany

[4 ]Department of Microbiology and Mycology, Dr. Wisplinghoff Laboratory, Cologne, Germany

[5 ]ISNI 0000 0001 2218 4662, GRID grid.6363.0, , Allergy-Centre-Charité, Charité-Universitätsmedizin, ; Berlin, Germany

[6 ]ISNI 0000 0004 0490 981X, GRID grid.5570.7, Experimental Pneumology, , Ruhr University, ; Bochum, Germany

[7 ]ISNI 0000 0000 8988 2476, GRID grid.11598.34, Institute for Hygiene, Microbiology and Environmental Medicine, , Medical University of Graz, ; Graz, Austria

[8 ]ISNI 0000 0000 8580 3777, GRID grid.6190.e, Department I for Internal Medicine and Cologne Excellence Cluster on Cellular Stress Responses in Aging-Associated Diseases (CECAD), , University of Cologne, ; Cologne, Germany

[9 ]ISNI 0000 0001 2240 3300, GRID grid.10388.32, Institute for Hygiene and Public Health, , Bonn University Hospital, ; Bonn, Germany

[10 ]Baden-Württemberg Regional Health Authorities at the Regional Council Stuttgart, Stuttgart, Germany

[11 ]Formerly: Baden-Württemberg Regional Health Authorities at the Regional Council in Stuttgart, Stuttgart, Germany

[12 ]ISNI 0000 0001 1958 8658, GRID grid.8379.5, Medical Clinic and Outpatient Clinic II with Special Focus on Infectiology, , Würzburg University Hospital, ; Würzburg, Germany

[13 ]Bavarian Office for Health and Food Safety, Munich, Germany

[14 ]ISNI 0000 0004 1936 973X, GRID grid.5252.0, Adj. Prof. “Hygiene and Environmental Medicine”, , Ludwig-Maximilian University, ; Munich, Germany

[15 ]Westend Allergy and Asthma Centre, Berlin, Germany

[16 ]Wiesbaden Centre for Rhinology and Allergology, Wiesbaden, Germany

[17 ]ISNI 0000000123222966, GRID grid.6936.a, Clinic and Outpatient Clinic for Dermatology and Allergology am Biederstein, , Technical University of Munich, ; Munich, Germany

[18 ]Medical Institute for Environmental and Occupational Medicine MIU GmbH, Erkrath, Germany

[19 ]Christian Children’s Hospital, Osnabrück, Germany

[20 ]ISNI 0000 0004 0490 981X, GRID grid.5570.7, , Institute for Prevention and Occupational Medicine of the German Social Accident Insurance, Institute of the Ruhr University Bochum (IPA), ; Bochum, Germany

[21 ]Leverkusen Asthma and Allergy Centre, Leverkusen, Germany

[22 ]ISNI 0000 0004 0477 2585, GRID grid.411095.8, Institute and Outpatient Clinic for Occupational, Social, and Environmental Medicine, Member of the German Centre for Lung Research, , Munich University Hospital, ; Munich, Germany

[23 ]Centre for Allergology and Asthma, Johanniter Hospital im Fläming Treuenbrietzen GmbH, Treuenbrietzen, Germany

[24 ]ISNI 0000000123222966, GRID grid.6936.a, Formerly: Chair of Microbiology and Clinic and Outpatient Clinic for Dermatology and Allergology am Biederstein, , Technical University of Munich, ; Munich, Germany

[25 ]ISNI 0000 0000 8584 9230, GRID grid.411067.5, Centre for Pediatric and Adolescent Medicine, , University Hospital Gießen and Marburg GmbH, ; Gießen, Germany

[26 ]Specialist Practice for Allergology and Pediatric Pneumology, Fulda, Germany

[27 ]FG (specialist field) II 1.4 Microbiological Risks, Federal Environmental Agency, Berlin, Germany

[28 ]ISNI 0000 0004 1936 973X, GRID grid.5252.0, Department and Outpatient Clinic for Dermatology and Allergology, , Ludwig-Maximilian University, ; Munich, Germany

Article

Publisher ID: 13

DOI: 10.1007/s40629-017-0013-3

PMC ID: 5533814

PubMed ID: 28804700

SO-VID: 26176014-3600-446e-98c5-45ded6d4f4b8

License:

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.