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德国卫生、环境医学与预防医学协会(GHUP)联合德国过敏症专科医生协会(AeDA)、德国皮肤病学会(DDG)、德国变态反应学与临床免疫学学会(DGAKI)、德国职业与环境医学学会(DGAUM)、德国医院卫生学会(DGKH)、德国肺病与呼吸医学学会(DGP)、德国真菌学会(DMykG)、儿科过敏症与环境医学学会(GPA)、德国联邦儿科学会(BAPP)以及奥地利医学真菌学会(ÖGMM)发布的室内霉菌暴露医学临床诊断AWMF指南简版:S2K指南

Abridged version of the AWMF guideline for the medical clinical diagnostics of indoor mould exposure: S2K Guideline of the German Society of Hygiene, Environmental Medicine and Preventive Medicine (GHUP) in collaboration with the German Association of Allergists (AeDA), the German Society of Dermatology (DDG), the German Society for Allergology and Clinical Immunology (DGAKI), the German Society for Occupational and Environmental Medicine (DGAUM), the German Society for Hospital Hygiene (DGKH), the German Society for Pneumology and Respiratory Medicine (DGP), the German Mycological Society (DMykG), the Society for Pediatric Allergology and Environmental Medicine (GPA), the German Federal Association of Pediatric Pneumology (BAPP), and the Austrian Society for Medical Mycology (ÖGMM).

作者信息

Wiesmüller Gerhard A, Heinzow Birger, Aurbach Ute, Bergmann Karl-Christian, Bufe Albrecht, Buzina Walter, Cornely Oliver A, Engelhart Steffen, Fischer Guido, Gabrio Thomas, Heinz Werner, Herr Caroline E W, Kleine-Tebbe Jörg, Klimek Ludger, Köberle Martin, Lichtnecker Herbert, Lob-Corzilius Thomas, Merget Rolf, Mülleneisen Norbert, Nowak Dennis, Rabe Uta, Raulf Monika, Seidl Hans Peter, Steiß Jens-Oliver, Szewszyk Regine, Thomas Peter, Valtanen Kerttu, Hurraß Julia

机构信息

Institute for Occupational Medicine and Social Medicine, University Hospital, Medical Faculty, RWTH Aachen University, Aachen, Germany.

Department of Infection Control and Environmental Hygiene, Cologne Health Authority, Neumarkt 15-21, 50667 Cologne, Germany.

出版信息

Allergo J Int. 2017;26(5):168-193. doi: 10.1007/s40629-017-0013-3. Epub 2017 Feb 28.

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 (), 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 () of the German Biological Agents Act (). 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 () 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 ().

摘要

本文是德国卫生、环境医学与预防医学协会()于2016年4月发布的AWMF霉菌指南“室内霉菌暴露的医学临床诊断”的节略版,该指南由上述科学医学协会、德国和奥地利各协会、医学协会及专家共同合作完成。室内霉菌滋生存在潜在健康风险,即便个别霉菌种类的出现与健康问题之间的定量和/或因果关系尚未确立。除过敏性支气管肺曲霉病(ABPA)和霉菌引起的真菌病外,仅已确立有充分证据表明潮湿/霉菌损害与以下健康影响之间存在关联:过敏性呼吸道疾病、哮喘(表现、进展和加重)、过敏性鼻炎、过敏性肺炎(外源性过敏性肺泡炎)以及呼吸道感染/支气管炎的可能性增加。在此背景下,与其他环境过敏原相比,霉菌的致敏潜力明显较低。近期研究表明,欧洲普通人群中致敏患病率相对较低,为3%至10%。关于黏膜刺激和特应性湿疹(表现、进展和加重),存在有限或可疑的关联证据。对于慢性阻塞性肺疾病、儿童急性特发性肺出血、风湿/关节炎、结节病和癌症,存在关联的证据不足或不充分。对于健康人而言,室内常见霉菌造成感染的风险较低;德国《生物制剂法》()规定,大多数霉菌种类属于风险1组,少数属于风险2组()。只有可能产生毒素的霉菌才会引发毒性反应。个别情况下是否产生毒素取决于环境和生长条件,首要因素是基质。对于室内潮湿/霉菌损害,每个人都可能受到气味影响和/或情绪障碍的影响。然而,这并非健康危害。气味影响的易感因素可能包括遗传和激素影响、印记、情境和适应效应。情绪障碍的易感因素可能包括环境担忧、焦虑、状况和归因,以及各种疾病。特别需要针对感染风险进行保护的风险群体,是根据位于罗伯特·科赫研究所(RKI)的德国医院卫生与感染预防委员会()的分类处于免疫抑制状态的人员以及患有囊性纤维化(黏液黏稠病)的人员;对于过敏风险,应保护患有囊性纤维化(黏液黏稠病)的人员和支气管哮喘患者。合理的诊断包括病史采集、体格检查以及必要时包括激发试验在内的常规过敏诊断;有时需要使用细胞检测系统。对于霉菌感染,读者可参考AWMF指南“侵袭性曲霉感染的诊断与治疗”。关于霉菌毒素,目前尚无用于临床诊断的有效且经过验证的检测程序。从预防医学角度来看,出于预防原因,不能容忍相关范围内的室内霉菌滋生。关于评估损害程度及选择补救措施,读者可参考德国联邦环境局发布的霉菌指南修订版。

https://cdn.ncbi.nlm.nih.gov/pmc/blobs/2b3a/5533814/d5c962c164ab/40629_2017_13_Fig1_HTML.jpg

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