The German guideline on medical clinical diagnostics for indoor mold exposure: key messages, 2024, Hurraß

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Hurraß, J., Wiesmüller, G.A. The German guideline on medical clinical diagnostics for indoor mold exposure: key messages. Allergo J Int (2024). https://doi.org/10.1007/s40629-024-00294-9

Abstract

The AWMF S2k guideline “Medical clinical diagnostics for indoor mold exposure” was introduced in 2016.

The guideline is based on a standardized procedure of the AWMF including a systematic literature search involving several medical disciplines.

The expert group has updated this guideline in accordance with AWMF specifications.

For this purpose, a new Medline search was carried out for the current version of the guideline up to June 2022 with additional search terms.

The search results were evaluated and further narrowed down by means of abstract screening and, where applicable, evidence-based evaluation of the full texts.

Medical guidelines on related topics were also taken into account.

The updated guideline is available since October 2023.

This is intended to close the existing knowledge gap for rational and efficient medical diagnostics for indoor mold contamination and provides 26 core statements and recommendations, which are presented in detail.

 

"Chronic fatigue syndrome (CFS)

In contrast to the previously discussed syndromes, only a few studies address a possible link between indoor dampness/mold exposure and CFS [24, 214, 662].

Here, too, is assumed that CFS etiologically has multifactorial genesis with biological, social and psychological factors [375]. In addition, the Committee on the Diagnostic Criteria for Myalgic Encephalomyelitis/Chronic Fatigue Syndrome, Board on the Health of Select Populations, Institute of Medicine has issued a 304-page statement on the subject of myalgic encephalomyelitis/CFS [109], in which terms such as mold, mycotoxins, or MVOCs are not mentioned.

To date, there is insufficient evidence of a causal link between the environmental medical syndromes SBS, MCS, and CFS and indoor exposure to moisture/mold [286].

In summary, there is sufficient evidence for an association between indoor dampness/mold exposure and disease patterns that can be correctly classified as BRI (building-related illness) by definition, if there is a clear exposure-related association [366]. This conditionally includes the diseases listed in Table 4 in chapter 2.3 under “Sufficient evidence for an association”.

However, there is inadequate or insufficient evidence for a link between indoor moisture/mold exposure and the environmental medical syndromes SBS, MCS, and CFS (see Table 4 in chapter 2.3).

Newly coined terms such as biotoxicosis and mold and dampness hypersensitivity syndrome (MDHS) [719, 728] or volatoxins [47], suggest a nosological specificity of a pathophysiological connection for which there is no evidence to date."

 

I think mould exposure will certainly come out as a risk factor for worse “CFS” outcomes because people with CFS are people, and people are humans and mould in buildings is bad for humans so if you’re someone susceptible to CFS or whatever other illness you’re going to be disadvantaged by the extra assault on your immune system of mould.

Also plenty of people have been diagnosed with CFS or ME because they have the symptoms of this but they later discover that the can largely recover by relocating away from the toxic moulds and treating their bodies for the mould poisoning.

I don’t think ME is mould poisoning but I am sure that mould poisoning plays a part in the condition, as people with ME or the vulnerability to getting it will be less robust in their ability to function with this extra assault on their bodies. But mould kills people so as above it’s not just a chronic illness issue, it’s an everyone issue.

 

Medical clinical diagnostics for indoor mould exposure – Update 2023 (AWMF Register No. 161/001), 2024, Hurraß et al

This article is an abridged version of the updated AWMF mould guideline "Medical clinical diagnostics in case of indoor mould exposure - Update 2023", presented in July 2023 by the German Society of Hygiene, Environmental Medicine and Preventive Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin, GHUP), in collaboration with German and Austrian scientific medical societies, 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. There is no evidence for a causal relationship between moisture/mould damage and human diseases, mainly because of the ubiquitous presence of fungi and hitherto inadequate diagnostic methods.

Sufficient evidence for an association between moisture/mould damage and the following health effects has been established for: allergic respiratory diseases, allergic rhinitis, allergic rhino-conjunctivitis, allergic bronchopulmonary aspergillosis (ABPA), other allergic bronchopulmonary mycosis (ABPM), aspergilloma, Aspergillus bronchitis, asthma (manifestation, progression, exacerbation), bronchitis (acute, chronic), community-acquired Aspergillus pneumonia, hypersensitivity pneumonitis (HP; extrinsic allergic alveolitis (EEA)), invasive Aspergillosis, mycoses, organic dust toxic syndrome (ODTS) [workplace exposure], promotion of respiratory infections, pulmonary aspergillosis (subacute, chronic), and rhinosinusitis (acute, chronically invasive, or granulomatous, allergic). In this context the sensitizing potential of moulds is obviously low compared to other environmental allergens. Recent studies show a comparatively low sensitization prevalence of 3-22,5 % in the general population across Europe.

Limited or suspected evidence for an association exist with respect to atopic eczema (atopic dermatitis, neurodermatitis; manifestation), chronic obstructive pulmonary disease (COPD), mood disorders, mucous membrane irritation (MMI), odor effects, and sarcoidosis. (iv)

Inadequate or insufficient evidence for an association exist for acute idiopathic pulmonary hemorrhage in infants, airborne transmitted mycotoxicosis, arthritis, autoimmune diseases, cancer, chronic fatigue syndrome (CFS), endocrinopathies, gastrointestinal effects, multiple chemical sensitivity (MCS), multiple sclerosis, neuropsychological effects, neurotoxic effects, renal effects, reproductive disorders, rheumatism, sick building syndrome (SBS), sudden infant death syndrome, teratogenicity, thyroid diseases, and urticaria.

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, water activity, temperature and above all the growth substrates.In case of indoor moisture/mould damage, everyone can be affected by odor effects and/or mood disorders.However, this is not an acute health hazard.

Predisposing factors for odor 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 regarding infection risk are immunocompromised persons 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), persons suffering from severe influenza, persons suffering from severe COVID-19, and persons with cystic fibrosis (mucoviscidosis); with regard to allergic risk, persons with cystic fibrosis (mucoviscidosis) and patients with bronchial asthma must 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 specific guidelines. Regarding mycotoxins, there are currently no useful and validated test procedures for clinical diagnostics. From a preventive medical point of view, it is important that indoor mould infestation in relevant magnitudes cannot be tolerated for precautionary reasons.For evaluation of mould damage in the indoor environment and appropriate remedial procedures, the reader is referred to the mould guideline issued by the German Federal Environment Agency (Umweltbundesamt, UBA).

Open access, https://www.thieme-connect.de/products/ejournals/html/10.1055/a-2194-6914