Occupational exposure to Aspergillus section Fumigati: Tackling the knowledge gap in Portugal.

Aspergillus section Fumigati is one of the sections of the Aspergillus genus most often associated with respiratory symptoms. The azole-resistant clinical isolates in this section have been widely described worldwide. More recently, the environmental origin of azole resistance has been correlated with the development of fungal diseases and therapeutic failure. This paper presents a review of several studies performed in Portuguese occupational environments focusing on occupational exposure to this section and give guidance to exposure assessors and industrial hygienists to ensure an accurate exposure assessment. Future studies should tackle the limitations concerning the assessment of occupational exposure to the Fumigati section, in order to allow the implementation of adequate risk management measures. In the light of the results of previous studies, the following approach is proposed to ensure an accurate exposure assessment: a) a combination of active and passive sampling methods appropriate to each occupational environment; b) the use, in parallel, of culture-based methods and molecular tools to overcome the limitations of each method; c) evaluation of the mycobiota azole resistance profile; and d) consider the possible simultaneous presence of mycotoxins produced by this section when assessing workers occupational exposure. In sum, preventing the development of fungal strains resistant to azoles will only be achieved with a holistic approach. An adequate "One Health approach" can contribute positively to concerted actions in different sectors, by reducing the use of fungicides through the introduction of crops and agricultural practices that prevent fungal colonization, and by promoting the rational use of antifungal drugs in human and animal health.