AWMF mold guideline "Medical clinical diagnostics for indoor mold exposure" - Update 2023 AWMF Register No. 161/001.

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Indoor Mold­Important Considerations for Medical Advice to Patients.

BACKGROUND: According to self-reported frequencies, every fifth or sixth dwelling in Germany is affected by dampness and/or mold. This carries a potential risk to health. METHODS: This review is based on pertinent publications retrieved by a selective literature search and inquiry in the GENESIS database, on the AWMF guideline on the medical clinical diagnosis of indoor mold exposure, as updated in 2023, and on the relevant contents of other current guidelines. Based on this research, we present an algorithm for the evaluation of health problems that may be due to mold in indoor environments. RESULTS: A rational diagnostic work-up begins with history-taking and physical examination, with attention to risk factors-above all, immune compromise and atopy. If there is evidence of atopy, targeted allergy diagnostics should be performed, consisting of a skin prick test and/or measurement of specific IgE antibodies, supplemented whenever indicated by provocative testing and cellular test systems. If the patient's immune response is compromised, the immediate cessation of mold exposure has absolute priority. Any suspected invasive fungal infection should be evaluated with radiological, microbiological, serological, and immunological testing. Indoor measurements of mold fungi, microbial volatile organic compounds (MVOC), and/or mycotoxins are generally not indicated as part of the medical evaluation; nor are blood or urine tests for particular mold components or metabolites. CONCLUSION: Mold in indoor environments should be dealt with by rapid exposure elimination for patients at risk, the rational diagnostic evaluation of any symptoms and signs of disease, and patient education about the possibilities and limitations of diagnostic testing and the generally limited utility of measurements in the affected interior spaces.

[Test Concept of the City of Cologne for Critical Infrastructure (KRITIS) during the First Wave of the COVID-19 Pandemic]. / Testkonzept der Stadt Köln für die Kritische Infrastruktur (KRITIS) in der ersten Welle der Corona-Pandemie.

BACKGROUND: At the beginning of the COVID-19 pandemic, the Public Health Department of the City of Cologne established preferential testing for critical infrastructure (KRITIS) personnel. The aim of this study was to retrospectively analyze this concept. METHODS: Test results as well as demographic and job-related data from March to April 2020 were collected and descriptively analyzed using a specially developed software. KRITIS personnel who tested positive were systematically interviewed over the phone. RESULTS: 1521 individuals were tested, of whom 896 (59%) were from the healthcare sector, particularly from the nursing professions (35%). Testing and consultation services were also utilized by employees of non-profit organizations (8%), administration (7%), fire department (11%), and police (4%). KRITIS personnel who tested positive suspected increased risk from contacts at the workplace (58%), mostly without adequate protection (85%). Of those surveyed, 83% rated the KRITIS concept as 'good' or 'very good'. Processes at the testing center were rated as 'good' or 'very good' by 89%, while 47% rated phone support as 'good' or 'very good', and 30% as 'sufficient' or poor. Free comments showed that frequent phone contact from the Public Health Department was perceived as positive and even more often as negative interindividually. Communication and advice were positively highlighted, while lack of competence and coordination were criticized. The respondents criticized the comparatively lower provision of testing services for family members, for example, due to limited resources. CONCLUSION: With the KRITIS concept, the Public Health Department of Cologne developed and implemented an offer for system-relevant professional groups that was intensively used and mostly assessed as positive. This concept can be used as a blueprint for other pandemics.

[From the practice of monitoring SARS-CoV-2 test sites in the city of Cologne]. / Aus der Praxis der Überwachung der SARS-CoV-2-Teststellen im Stadtgebiet Köln.

In spring 2021, a law for the nationwide opening of test centers in Germany was passed. The local health department fulfilled the task of monitoring the test centers that subsequently opened throughout Cologne regarding the infectious and hygienic risks. Inspections were carried out using structured checklists. A retrospect evaluation of the identified deficiencies was run for the period between March 15 and July 31, 2021. In 84% of the cases, hygienic deficiencies were found when the test sites were inspected for the first time. 35% of the test sites were closed immediately, most of them temporarily. These first results provide information on frequent and important hygienic problems of the rapid set up of test sites and important advice for avoiding those and thus protecting employees and test persons.

[Spreading Dynamics of the Alpha and Beta Virus Variants of SARS-CoV-2 at the Beginning of Their Appearance in the City of Cologne in January and February 2021]. / Ausbreitungsdynamik der Alpha- und Beta-Virusvarianten von SARS-CoV-2 zum Beginn ihres Auftretens in der Stadt Köln im Januar und Februar 2021.

BACKGROUND AND AIM OF THE STUDY: Constantly changing virus variants of the novel coronavirus SARS-CoV-2 pose major challenges to the healthcare system. The aim of the present study was to analyse major outbreaks of the alpha and beta variants in Cologne in order to enable effective and rapid response to new virus variants in future pandemics as well as to derive targeted measures to combat the pandemic. METHODS: In the observation period from January 22 to February 23, 2021, all individuals testing positive for SARS-CoV-2 and their contact persons who were reported to the Cologne Public Health Department were interviewed by employees of the Public Health Department over the telephone. On the one hand, these data formed the basis for the epidemiological and descriptive comparison of the alpha and beta variants to the previously dominant wild type. On the other hand, they were also the basis for the graphical processing of clusters formed by the two virus variants in the form of so-called timelines. For the present work, all clusters with ≥10 individuals were taken into account for the period under consideration. RESULTS: Of the 3780 individuals that tested positive for SARS-CoV-2 in Cologne during the observation period, 818 cases were due to the virus variants alpha and beta. The alpha versus the beta variant spread quickly in Cologne despite strict non-pharmaceutical interventions. As part of the cluster analysis, five major outbreak were identified in Cologne during the observation period. The alpha variant clusters included two daycare centers and one monastery, while the beta variant clusters included a communal accommodation for refugees and an old people's and nursing home. With the help of cluster analysis, the core role of the spread of the virus variants examined was shown, especially in the context of the home setting. In addition, a high proportion of cases of unknown infection site/contact was found for the wild type and alpha variant. CONCLUSION: Cluster analyses are an extremely useful tool in the determination of infection sites/contacts and transmission paths as well as in determining existing protective measures and hygiene concepts. Since clusters are to be regarded as the most unfavorable spread scenario, cluster analyses provide important suggestions for modifying further action for both this, as well as for future pandemics.

Formaldehyde, aliphatic aldehydes (C2 -C11 ), furfural, and benzaldehyde in the residential indoor air of children and adolescents during the German Environmental Survey 2014-2017 (GerES V).

Indoor air concentrations of formaldehyde, furfural, benzaldehyde, and 11 aliphatic aldehydes (C2 -C11 ) were measured in residences of 639 participants in the German Environmental Survey for Children and Adolescents 2014-2017 (GerES V). Sampling was conducted using passive samplers over periods of approximately seven days for each participant. The most abundant compounds were formaldehyde and hexanal with median concentrations of 24.9 µg m-3 and 10.9 µg m-3 , respectively. Formaldehyde concentrations exceeded the Guide Value I recommended by the German Committee on Indoor Guide Values (Ausschuss für Innenraumrichtwerte - AIR) (0.10 mg m-3 ) for 0.3% of the participating residences. The sum of aliphatic n-aldehydes between C4 (butanal) and C11 (undecanal) exceeded their Guide Value (0.10 mg m-3 ) for 2.0% of the residences. The geometric mean concentrations of most aldehydes were lower than in the earlier GerES IV (2003-2006) study. Formaldehyde and hexanal concentrations, however, were comparable in both studies and showed no significant difference. Indoor aldehyde concentrations did not exhibit significant correlations with factors collected in questionnaires, such as the age of the participants, their socio-economic status, the location of the residence (former East/West Germany), migration background, tobacco exposure, and the type of furniture used. The validity of the passive sampler measurements was verified against active sampling techniques in a test chamber experiment.

COVID-19 Breakthrough Infections and Transmission Risk: Real-World Data Analyses from Germany's Largest Public Health Department (Cologne).

BACKGROUND AND METHODS: Vaccination is currently considered the most successful strategy for combating the SARS-CoV-2 virus. According to short-term clinical trials, protection against infection is estimated to reach up to 95% after complete vaccination (≥14 days after receipt of all recommended COVID-19 vaccine doses). Nevertheless, infections despite vaccination, so-called breakthrough infections, are documented. Even though they are more likely to have a milder or even asymptomatic course, the assessment of further transmission is highly relevant for successful containment. Therefore, we calculated the real-world transmission risk from fully vaccinated patients (vaccination group, VG) to their close contacts (CP) compared with the risk from unvaccinated reference persons matched according to age, sex, and virus type (control group = CG) utilizing data from Cologne's health department. RESULTS: A total of 357 breakthrough infections occurred among Cologne residents between 27 December 2020 (the date of the first vaccination in Cologne) and 6 August 2021. Of the 979 CPs in VG, 99 (10.1%) became infected. In CG, 303 of 802 CPs (37.8%) became infected. Factors promoting transmission included non-vaccinated status (ß = 0.237; p < 0.001), male sex (ß = 0.079; p = 0.049), the presence of symptoms (ß = -0.125; p = 0.005), and lower cycle threshold value (ß = -0.125; p = 0.032). This model explained 14.0% of the variance (corr. R2). CONCLUSION: The number of transmissions from unvaccinated controls was three times higher than from fully vaccinated patients. These real-world data underscore the importance of vaccination in enabling the relaxation of stringent and restrictive general pandemic control measures.

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).

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).

Medical diagnostics for indoor mold exposure.

In April 2016, the German Society of Hygiene, Environmental Medicine and Preventative Medicine (Gesellschaft für Hygiene, Umweltmedizin und Präventivmedizin (GHUP)) together with other scientific medical societies, German and Austrian medical societies, physician unions and experts has provided an AWMF (Association of the Scientific Medical Societies) guideline 'Medical diagnostics for indoor mold exposure'. This guideline shall help physicians to advise and treat patients exposed indoors to mold. Indoor mold growth is a potential health risk, even without a quantitative and/or causal association between the occurrence of individual mold species and health effects. Apart from the allergic bronchopulmonary aspergillosis (ABPA) and the mycoses caused by mold, there is only sufficient evidence for the following associations between moisture/mold damages and different health effects: Allergic respiratory diseases, asthma (manifestation, progression, exacerbation), allergic rhinitis, exogenous allergic alveolitis and respiratory tract infections/bronchitis. In comparison to other environmental allergens, the sensitizing potential of molds is estimated to be low. Recent studies show a prevalence of sensitization of 3-10% in the total population of Europe. The evidence for associations to mucous membrane irritation and atopic eczema (manifestation, progression, exacerbation) is classified as limited or suspected. Inadequate or insufficient evidence for an association is given for COPD, acute idiopathic pulmonary hemorrhage in children, rheumatism/arthritis, sarcoidosis, and cancer. The risk of infections from indoor molds is low for healthy individuals. Only molds that are capable to form toxins can cause intoxications. The environmental and growth conditions and especially the substrate determine whether toxin formation occurs, but indoor air concentrations are always very low. In the case of indoor moisture/mold damages, everyone can be affected by odor effects and/or impairment of well-being. Predisposing factors for odor effects can be given by genetic and hormonal influences, imprinting, context and adaptation effects. Predisposing factors for impairment of well-being are environmental concerns, anxieties, conditioning and attributions as well as a variety of diseases. Risk groups that must be protected are patients with immunosuppression and with mucoviscidosis (cystic fibrosis) with regard to infections and individuals with mucoviscidosis and asthma with regard to allergies. If an association between mold exposure and health effects is suspected, the medical diagnosis includes medical history, physical examination, conventional allergy diagnosis, and if indicated, provocation tests. For the treatment of mold infections, it is referred to the AWMF guidelines for diagnosis and treatment of invasive Aspergillus infections. Regarding mycotoxins, there are currently no validated test methods that could be used in clinical diagnostics. From the perspective of preventive medicine, it is important that mold damages cannot be tolerated in indoor environments.

Fine and ultrafine particles emitted from laser printers as indoor air contaminants in German offices.

PURPOSE: Various publications indicate that the operation of laser printers and photocopiers may be associated with health effects due to the release of gaseous components and fine and ultrafine particles (UFP). However, only sparse studies are available that evaluate the possible exposure of office workers to printer emissions under real conditions. Therefore, the aim of our study was to assess the exposure of office workers to particulate matter released from laser printers and photocopiers. METHODS: Concentrations of fine particles and UFP were measured before, during, and after the operation of laser printing devices in 63 office rooms throughout Germany. Additionally, the particles were characterized by electron microscopy and energy-dispersive X-ray spectroscopy. RESULTS: A significant increase of fine particles and UFP was identified in ambient workplace air during and after the printing processes. Particle fractions between 0.23 and 20 µm emitted by the office machines significantly affect particle mass concentrations while printing 500 pages, i.e., during the printing process, PM(0.23-20), PM(2.5), and PM(10) concentrations increased in 43 out of the evaluated 62 office rooms investigated. Additionally, a significant increase was observed in submicrometer particles, with median particle number concentrations of 6,503 particles/cm(3) before and 18,060 particles/cm(3) during the printing process. CONCLUSIONS: Our data indicate that laser printers and photocopiers could be a relevant source of fine particles and particularly UFP in office rooms.

Is glassiness a common characteristic of soil organic matter?

Until now, glass transitions were detected in isolated humic and fulvic acids as well as in distinct soil samples with usually high Corg contents. The results of this study indicate that glassiness has to be considered a common characteristic of soil organic matter (SOM). However, two types of glassiness were observed in various soil types. Additionally to a typical glass transition with low intensity, a slowly reversing glasstransition-like step transition with significantly higher intensity was detected in 52 out of 102 tested soil samples. The intensity of this transition type is correlated to the organic matter content of the samples. The transition behavior additionally depends on characteristics of the locations and changes within soil profiles. Relations to particulate organic matter (POM), mineral-associated organic matter (MOM), and the thermostable fraction of the soil samples were not significant. A surprising result of the study is that the step transition temperatures of all analyzed air-dried soil samples range between 51 and 67 degrees C in closed systems, pointing to a superordinate mechanism which controls the matrix rigidity of the organic molecules. This may be represented by the formation of hydrogen bond based cross-links between water molecules and SOM suggested in a previous study. Thus, glassiness in SOM may be caused by physical and physicochemical mechanisms.